European Journal of Cardio-Thoracic Surgery最新文献

Objectives: Complex congenital hearts could be deemed 'unseptatable' or unsuitable for biventricular circulation. We described our novel approach to utilize the left ventricle (LV) as the sub-pulmonary ventricle, termed 'ventricular switch'. We report our updated experience and highlight lessons learned.

Methods: This is a retrospective cohort study (2016-2023) of patients who underwent ventricular switch, which utilizes series of surgical techniques resulting in a biventricular circulation with a sub-systemic right ventricle (RV). These patients were selected when LV-based biventricular repair was not feasible, or with a failing single-ventricle physiology. The majority of these cases are complex heterotaxy with complex systemic and pulmonary connections. Pre- and postoperative data were analysed, focusing on modifications from iterative experience.

Results: Seventeen patients underwent ventricular switch. Median conversion age was 5.2 years (4 months-47 years). Three (17%) had an operative mortality. Systemic saturation significantly improved postoperatively (79 ± 6 vs 94 ± 4, P = 0.008). Elevated central venous pressure (CVP) decreased by 13 mmHg ± 5 postoperatively. Eleven out of 17 (65%) patients underwent preemptive atrioventricular valve (AVV) repair as part of the procedure, and all maintained or improved AVV function postoperatively. One-year and 5-year survival was 79% and 72%, respectively. Patients demonstrated stable biventricular function, well-functioning AVV and improved symptoms.

Conclusions: Ventricular switch can be an option in complex lesions that are not amenable to LV based biventricular circulation. Our results demonstrate improvement in oxygen saturation, CVP and stable ventricular function at follow-up. Our experience suggests that systemic AVV competency is critical for satisfactory postoperative haemodynamics and outcomes. Successful surgery requires normal preoperative RV function and end-diastolic volumes.

Objectives: We previously did a randomized clinical trial of lobectomy by video-assisted thoracoscopic surgery (VATS) or thoracotomy for early-stage lung cancer and found that patients who underwent VATS had less postoperative pain and better quality of life compared with thoracotomy. VATS has since been regarded the preferred surgical method for early-stage lung cancer. It is assumed that long-term survival is not influenced by surgical approach, but this assumption primarily rests on non-randomized comparative studies. We decided to do a long-term follow-up of patients who entered our previous randomized trial.

Methods: Between 2008 and 2014, we randomly assigned 206 patients to VATS (n = 103) or anterolateral thoracotomy (n = 103) for proven or suspected early-stage non-small-cell lung cancer (NSCLC). Records from patients with NSCLC on final pathology were identified in the national electronic patient-record system and the Danish Lung Cancer Registry. Overall, disease-free and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method and log-rank test was used to compare the 2 interventions.

Results: A total of 196 patients had NSCLC on final histopathology. Four patients were lost to follow-up and the remaining 192 were included in this follow-up study with 128 events used for overall survival analysis, 100 events for disease-free survival analysis and 79 events for CSS analysis. VATS was used in 99 patients versus 93 by thoracotomy. Median age at time of surgery was 66 years (range 41-85 years). After a median follow-up time of 12.8 years (range 9.9-15.8 years), 33% of patients were alive. Overall, disease-free and CSS were not significantly different between VATS and thoracotomy: overall survival (P = 0.29), disease-free survival (P = 0.17) and CSS (P = 0.31).

Conclusions: We did not find any statistically significant differences in overall, disease-free or CSS between VATS and thoracotomy. However, larger trials with better power for survival analysis are needed to fully explore if there are differences. Alternatively, differences in survival between thoracotomy and VATS for early-stage NSCLC could be investigated by pooling survival data from 2 similar randomized trials that have since been published.

Objectives: To investigate and quantify differences in survival and reinterventions between sexes after aortic root replacement with a stentless bioprosthesis, stratified for preoperative valve lesion.

Methods: Elective adults undergoing aortic root replacement with the Freestyle bioprosthesis at six North-Atlantic centres were included. Survival analyses were performed using the Kaplan-Meier method or Aalen-Johansen with death as competing risk as relevant. Results were quantified using uni- and multivariable Cox regression tested using a log-rank likelihood ratio test.

Results: In total, 884 patients were analysed for a median follow-up time of 10 years. Females were 4 years older. Survival was significantly worse in females operated for aortic valve insufficiency [60.7% and 72.2% for females and males at 14 years, respectively (P = 0.001)], but not for the other indications, even after correction for age. There were no differences in early outcomes or need for reoperation between the sexes and between the different aortic valve pathologies.

Conclusions: Sex difference in survival outcomes depends on pathology, and females have, compared to males, more symptoms preoperatively regardless of type of valve lesion and worse outcome after aortic root replacement due to aortic insufficiency. Updated surgical risk scores should account for interaction between sex and pathology, and the surgical community must raise awareness on risk of patient's or doctors delay to surgery.

Objectives: The impact of tumour spread through air spaces (STAS) on the prognosis of synchronous multiple primary lung adenocarcinoma (sMPLA) remains unclear. This study evaluates the prognostic significance of STAS in early-stage sMPLA and its combined effect with surgical strategies.

Methods: Patients with cT1-3N0M0 sMPLA (2012-2018) were selected based on multidisciplinary team evaluation, surgical confirmation of invasive adenocarcinoma and exclusion of metastases or minimally invasive disease. Prognostic variables were selected using the least absolute shrinkage and selection operator regression with grouped variables. Survival outcomes were analysed via Cox proportional-hazards models for overall survival and Fine & Gray competing risk regression for recurrence-free survival.

Results: Among 131 patients, STAS was observed in 68 (51.9%), including 21 (16.0%) with STAS in both tumours (bi-STAS) and 47 (35.9%) with STAS in one tumour. Bi-STAS independently predicted worse overall survival (hazard ratio = 3.78, 95% confidence interval: 1.23-11.65, P = 0.020) and recurrence-free survival (hazard ratio = 3.99, 95% confidence interval: 1.34-11.93, P = 0.013). Patients with bi-STAS had significantly lower overall survival (P < 0.001) and higher cumulative incidence of recurrence (P < 0.001) compared to mono-STAS/un-STAS groups. Notably, bi-STAS patients showed similar survival outcomes whether undergoing lobectomy or sublobar resection (overall survival: P = 0.889; recurrence-free survival: P = 0.857), underscoring limited benefit from extensive surgery.

Conclusions: Concurrent bi-STAS is a strong prognostic marker for early-stage sMPLA, independent of surgical strategy. Comprehensive STAS evaluation in all dominant tumours is critical for postoperative risk stratification.

Objectives: The left medial basal pulmonary segment (S7) has been largely overlooked in surgical literature due to the common belief that it is typically absent. This study aimed to determine the prevalence of left S7, identify its anatomical characteristics and evaluate outcomes in patients undergoing S7 segmentectomy.

Methods: We retrospectively analysed 1440 patients who underwent thoracoscopic segmentectomy for ground-glass opacity in the left lower lobe between January 2019 and February 2022 at our hospital. Three-dimensional computed tomography bronchography and angiography (3D-CTBA) images were reconstructed for all patients. The principal outcome was the prevalence and anatomical variation of S7. Secondary outcomes included surgical feasibility and short-term outcomes of S7 segmentectomy.

Results: Six types of left medial basal bronchus (B7) were identified. Type 1: B7 arose from B8 (61.4%); type 2: B7 arose higher than B8-B10 (6.3%); type 3: B7 arose from B9 (5.5%); type 4: B7 arose from both B8 and B9 (1.6%); type 5: B7 arose from both B8 and B10 (0.8%); type 6: B7 was absent (24.4%). Nine (0.6%) patients with nodules in S7 underwent successful thoracoscopic segmentectomy, with no major complications or conversions to lobectomy.

Conclusions: Left S7 is present in approximately 75% of patients. The complex branching patterns of B7 identified highlight the importance of preoperative 3D-CTBA for accurate surgical planning. Our findings suggest that left S7 segmentectomy is feasible and safe when performed with precise anatomical understanding, expanding surgical options for patients with early-stage lung cancer in this segment.

Objectives: Randomized clinical trials (RCTs) are the gold standard for comparative effectiveness. However, they face unique challenges in cardiac surgery. The objective of this work is to summarize the challenges of RCTs in cardiac surgery, describe efforts employed in recent years to mitigate these impediments and outline the future opportunities for increased RCT adoption in the specialty.

Methods: This review was conducted as an expert analysis on the existing state of RCTs in cardiac surgery based on expert discussion at a dedicated session during the 2024 Annual Meeting of the European Association for Cardio-Thoracic Surgery (EACTS). Different trial-support infrastructures, such as the Randomized Comparison of the Clinical Outcomes of Single versus Multiple Arterial Grafts (ROMA) Network, the Cardiothoracic Surgical Trials Network (CTSN), the Global Cardiovascular Research Funders Forum (GCRFF) and the UK Model, and their respective mechanisms for overcoming RCT barriers were described in detailed. Models were selected due to specific author involvement and knowledge. Future directions were postulated based on current trends.

Results: Despite heterogeneous structures, the described models largely aimed to increased cardiac RCTs through improved trial participation, either via increased trainees, expanded stakeholders or focused patient recruitment, facilitating funding and fostering wider collaboration.

Conclusions: RCTs are a key component for clinical advancement yet have been underutilized in cardiac surgery. Recent endeavours have reduced the multifactorial barriers associated with cardiac surgery RCTs and intentional future efforts are necessary for continued cardiac advancement.

Objectives: We investigated the relationship between aortic arch configuration and reconstruction methods used in the Norwood procedure.

Methods: Our surgical database identified 162 patients who underwent the Norwood procedure for hypoplastic left heart syndrome, including variants, from January 2010 to December 2023. Of the 162 total cases, this study focused on the 135 patients who were assessed using computed tomography and aortic angiography. We have mainly employed direct anastomosis (direct), patch augmentation using an autologous pericardium (patch) and the chimney technique (chimney: another autologous reconstruction) as the methods for aortic arch reconstructions. According to the configurations of the postoperative aorta, arch geometry was defined as the Gothic, Crenel and Romanesque types. The following parameters were analysed: rates of intervention for recurrent coarctation (re-CoA), aortic distensibility and degree of tapering in the reconstructed aortic arch.

Results: The Gothic, Crenel and Romanesque were observed in 18 (13.3%), 48 (35.6%) and 69 (51.1%) patients, respectively. Direct tends to induce Gothic configuration, whereas the Romanesque was frequently observed in the chimney. Direct (23.5%) and Gothic (33.3%) showed higher rates of re-CoA, while the chimney (1.8%) showed a lower rate. Furthermore, distensibility was higher in chimney (5.3 mmHg-1 in median) compared to the 2 other methods (direct: 3.2 mmHg-1, patch: 2.1 mmHg-1 in median). Additionally, the chimney showed lower tapering of the reconstructed aortic arch (chimney: 2.9 mm vs direct: 4.1 mm and patch: 3.5 mm in median).

Conclusions: Our findings suggested that the chimney technique was associated with a more favourable postoperative aortic configuration, lower rate of re-CoA and higher aortic distensibility than the other methods.

Objectives: Reliable methods for predicting pathological complete response (pCR) in non-small cell lung cancer (NSCLC) patients undergoing neoadjuvant chemoimmunotherapy are still under exploration. Although Fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) features reflect tumour response, their utility in predicting pCR remains controversial.

Methods: This retrospective analysis included NSCLC patients who received neoadjuvant chemoimmunotherapy followed by 18F-FDG PET/CT imaging at Shanghai Pulmonary Hospital from October 2019 to August 2024. Eligible patients were randomly divided into training and validation cohort at a 7:3 ratio. Relevant 18F-FDG PET/CT features were evaluated as individual predictors and incorporated into 5 machine learning (ML) models. Model performance was assessed using the area under the receiver operating characteristic curve (AUC), and Shapley additive explanation was applied for model interpretation.

Results: A total of 205 patients were included, with 91 (44.4%) achieving pCR. Post-treatment tumour maximum standardized uptake value (SUVmax) demonstrated the highest predictive performance among individual predictors, achieving an AUC of 0.72 (95% CI 0.65-0.79), while ΔT SUVmax achieved an AUC of 0.65 (95% CI 0.53-0.77). The Light Gradient Boosting Machine algorithm outperformed other models and individual predictors, achieving an average AUC of 0.87 (95% CI 0.78-0.97) in training cohort and 0.83 (95% CI 0.72-0.94) in validation cohort. Shapley additive explanation analysis identified post-treatment tumour SUVmax and post-treatment nodal volume as key contributors.

Conclusions: This ML models offer a non-invasive and effective approach for predicting pCR after neoadjuvant chemoimmunotherapy in NSCLC.

Objectives: Video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) are widely used in the treatment of anterior mediastinal lesions. However, recent reports comparing the efficacy of VATS and RATS remain unclear, owing to limitations, including territorial constraints, small sample sizes or lack of subgroup analysis. Thus, we conducted a multi-centre retrospective study to compare perioperative outcomes of VATS and RATS via lateral thoracic or subxiphoid approach for anterior mediastinal lesions.

Methods: Patients with anterior mediastinal lesions from 3 high-volume Chinese centres were included. VATS and RATS via lateral thoracic or subxiphoid approaches were performed. A propensity score-matching analysis was conducted with covariates including sex, smoking, alcohol, hypertension, diabetes, myasthenia gravis symptoms, lesion diameter, pathology and blood test results.

Results: A total of 1076 patients (954 VATS, 122 RATS) were included. For the lateral thoracic approach, 122 VATS and 62 RATS patients were matched. RATS resulted in shorter catheter retention (P < 0.001), shorter postoperative stays (P = 0.002) and lower complication rates (P < 0.001), with no conversions or re-surgeries. For the subxiphoid approach, 98 VATS and 52 RATS patients were matched. RATS demonstrated higher drainage volume (P < 0.001), longer catheter retention (P = 0.03) and greater albumin reduction (P < 0.001), with no conversions or re-surgeries.

Conclusion: Using the lateral thoracic approach, RATS offered shorter catheter retention, shorter postoperative stays and fewer complications. However, with the subxiphoid approach, RATS led to higher drainage volume and longer catheter retention. Our study indicates that surgical approach impacts outcomes, with RATS being more beneficial for lateral thoracic cases and VATS for subxiphoid cases.

Objectives: Individuals with congenital heart disease (CHD) face daily life limitations, increasing the risk of anxiety and depression. Diagnosing these disorders in adults with CHD (ACHD) remains challenging in the clinical routine, because physical symptoms can be misattributed to a patient's physical condition. Several screening instruments are available, and studies revealed that they can be used to diagnose varying numbers of people with clinically relevant symptoms. Therefore, we compared frequently used screening tools for depression and anxiety in ACHD in Germany.

Methods: Participants were recruited from the German National Register for Congenital Heart Defects. A total of 1486 patients aged 18 to 85 (Mage = 36.84; 60.8% female) were classified as simple, moderate or complex CHD. Self-reported measures of depression [Hospital Anxiety and Depression Scale (HADS-D); Patient Health Questionnaire-9 (PHQ-9)], anxiety [Hospital Anxiety and Depression Scale (HADS-A); Generalized Anxiety Disorder-7 (GAD-7)], psychotherapy utilization, secondary illnesses and sociodemographic characteristics, were recorded.

Results: The PHQ-9 recorded about 39% more patients with depressive symptoms compared to the HADS-D. The GAD-7 detected approximately 15% more patients with anxiety symptoms in comparison to the HADS-A. PHQ-9 and GAD-7 demonstrated higher sensitivity (89.6%/86.8%) but lower specificity (48.1%/53.5%) compared to the HADS-D/HADS-A (sensitivity: 56.3%/78.0%; specificity: 87.8%/67.2%). No significant differences were found between the CHD severity levels.

Conclusions: The screening tools we compared were used to diagnose a significantly different number of patients with depression or anxiety in ACHD. Because even mild symptoms have a significant impact on quality of life, using PHQ-9 and GAD-7 in clinical practice is recommended to minimize false negatives and ensure mental health in ACHD.