European Journal of Cardio-Thoracic Surgery最新文献

Objectives: Aortic valve repair/sparing techniques have been established as effective treatments for aortic regurgitation and/or aortic aneurysms. However, concerns remain regarding long-term durability, reproducibility and patient selection. This study aims to asses long-term clinical and echocardiographic outcomes, with a focus on aortic regurgitation grade and left ventricular ejection fraction evolution, in adults undergoing these procedures.

Methods: Adult patients in the Heart Valve Society Aortic Valve Database, undergoing any aortic valve repair/sparing technique were included. Time-to-event analyses were used for clinical outcomes and mixed-effects models for left ventricular ejection fraction and aortic regurgitation grade evolution. Techniques: isolated valve repair (group 1), ascending aortic replacement + valve repair (group 2), partial-root replacement ± valve repair (group 3) and valve-sparing root replacement ± valve repair (group 4).

Results: Survival at 10 years was comparable to survival of the matched-general-population in each group. The 10-year cumulative incidence of reintervention was 19.5% [95% confidence interval (CI) 16.70-22.40%] in group 1 [including only double external annuloplasty in group 1; reintervention was not significantly different between techniques (P = 0.112)]; 13.8% (95% CI 10.10-18.10%) in group 2; 12.7% (95% CI 5.50-22.90%) in group 3; and 8.5% (95% CI 7.00-10.10%) in group 4 (P < 0.001). Severe preoperative aortic regurgitation grade [hazard ratio 1.95 (95% CI 1.19-3.21), P < 0.001] and left ventricular end-diastolic diameter [hazard ratio 1.03 (95% CI 1.00-1.05), P < 0.001] were predictive of reintervention in group 4; patch use was a predictor in all groups. The predicted left ventricular ejection fraction (%) initially increased (P < 0.001) and then stabilized.

Conclusions: This study found that aortic valve repair/sparing techniques provide viable and effective treatment options that should be considered for all eligible patients with aortic regurgitation and/or aortic root/ascending aortic aneurysms, given their potential to restore life expectancy and provide good haemodynamic outcomes with an acceptable hazard of reintervention.

Objectives: This study aimed to comprehensively compare the early and long-term clinical outcomes of bovine pericardial valve (BOV) and porcine valve (POV), specifically during the primary isolated aortic valve replacement (AVR), using data from the Korean National Health Insurance Service (NHIS) database.

Methods: Using the Korean NHIS claimed data, all adult patients (age ≥19) who underwent primary isolated AVR using bioprosthetic valve from 2003 to 2019 were identified and propensity-score matching (PSM) analysis was performed.

Results: Overall, 5470 patients with BOV (n = 3947, group B) or POV (n = 1,523, group P) were enrolled, of whom 814 pairs were matched in a 1:1 ratio using PSM analysis. Early postoperative mortality and morbidities were comparable between the groups before and after PSM, considering inter-hospital clustering. The cumulative incidence of all-cause mortality was higher in group P than in group B in the total cohort (group B 5.3%/patient-years vs group P 6.4%/patient-years, adjusted hazard ratio: 1.20, P = 0.002), whereas those differences in all-cause mortality disappeared in PSM analysis (P = 0.24). The cumulative incidences of late stroke, reoperation and infective endocarditis were not significantly different between the groups in PSM populations.

Conclusions: In Korean national database cohort patients with primary isolated AVR, there was no significant difference in the early- and long-term clinical outcomes between BOV and POV.

Objectives: Infective endocarditis with intervalvular fibrosa involvement is a life-threatening condition. Fibrous skeleton reconstructive options encompass variants of the 'Commando' operation dictated by surgical findings. We aim to review the characteristics and outcomes of patients undergoing different iterations of this operation.

Methods: Retrospective analysis of patients who underwent intervalvular fibrosa reconstruction in the setting of acute infective endocarditis at 2 national referral centres from April 2014 to November 2023. Patients were divided into 2 groups, regarding the extent of surgery at the aortic root level: non-ROOT ('Commando') and ROOT (Root-'Commando': commando with root replacement).

Results: Seventy-eight patients were included; 30 (38.5%) in the ROOT group and 48 (61.5%) the non-ROOT group. There were no differences in perioperative mortality, postoperative complications and follow-up reoperations or reinfections. There were no relapses in both groups. Median follow-up was 4.69 years (95% CI 3.10-5.13). Overall, in-hospital and/or 30-day mortality was 14 (17.9%), without differences between groups. Overall survival rates at 1 and 5 years were 76.2% and 67.2%, respectively. Overall survival was 74%, 74% and 68% in the non-ROOT group and 79%, 79% and 63% in the ROOT group, respectively, at 1, 2 and 5 years.

Conclusions: Variants of the 'Commando' operation offer stable cardiac fibrous skeleton reconstructions to patients without alternative repair options. Provided that surgical reconstruction is achieved, there are no differences in early and mid-term outcomes based on the use of root replacement. Absence of relapses can be achieved with these techniques.

Objectives: To assess whether ascending aorta over-angulation, a morphological feature recently found to be associated with acute type A aortic dissection, precedes dissection and how it affects wall stress distribution.

Methods: A baseline finite element model, previously created by a neural network tool from end-diastolic computed tomography angiography measurements in 124 healthy subjects, was modified to simulate the over-angulation accompanying aortic elongation, obtaining paradigmatic models with different ascending angulations (ascending-arch angle 145°-110°). The models were discretized and embedded in a deformable continuum representing surrounding tissues, aortic wall anisotropy and nonlinearity were accounted for, pre-tensioning at diastolic pressures was applied and peak systolic stresses were computed. Then, from 15 patients' pre-dissection geometries, patient-specific finite element models of pre-dissection aorta were created through the same framework. The sites of maximum longitudinal stress were compared with the respective sites of dissection entry tear in post-dissection imaging.

Results: Paradigmatic models showed that progressive narrowing of the ascending-arch angle was associated with increasing longitudinal stress (becoming significant for angles <130°), whereas the impact on circumferential stress was less consistent. In pre-dissection patient-specific models, the ascending-arch angle was narrowed (113°±11°), and the region of peak longitudinal stresses corresponded to the entry tear location in the respective post-dissection computed tomography angiography.

Conclusions: This study strongly supports the hypothesis that the ascending-arch angle, as quantifier of aorta over-angulation, can be a good predictor of aortic dissection, since its narrowing below 130° increases longitudinal wall stress, and the dissection entry tears develop in the aortic wall in areas of highest longitudinal stress.

Objectives: Electromagnetic navigation bronchoscopy (ENB) has been used to guide the diagnosis and treatment of pulmonary nodules. However, its combined application with real-time digital subtraction angiography (DSA), computed tomography (CT) and microwave ablation (MWA) for malignant pulmonary nodules has not been documented. This study aimed to evaluate the feasibility and safety of a novel technique that integrates ENB with real-time two-dimensional (2D) and three-dimensional (3D) imaging guidance for MWA of malignant pulmonary nodules.

Methods: Thirty-nine patients with 51 malignant pulmonary nodules underwent MWA using ENB with real-time DSA and cone-beam CT (CBCT). The 2D DSA was used to guide the positioning of the ablation probe in real-time, while 3D CBCT was performed before and after ablation to confirm the probe position and assess the ablation zone. The primary outcomes were technical success and complications. Secondary outcomes included navigation time, procedure time, radiation exposure and ablation parameters.

Results: The ENB-guided MWA with real-time 2D and 3D imaging guidance was technically successful in 92.2% (47/51) nodules. The median navigation time was 12 min, and the median total procedure time was 85 min. The median total radiation dose from the CBCT scans was 276 mGy. No major complications occurred. Minor complications included haemoptysis (n = 2) and postoperative fever (n = 3), which resolved spontaneously.

Conclusions: ENB combined with real-time 2D DSA guidance and 3D CBCT may be a feasible and safe technique for MWA of malignant pulmonary nodules.

Objective: We aimed to evaluate outcomes after Kawashima procedure with special regard to the development of pulmonary arterio-venous malformations.

Methods: All patients who underwent Kawashima procedure between 1992 and 2022 were reviewed.

Results: Twenty-one patients underwent Kawashima procedure at a median age of 14.5 (interquartile range, 8.4-40.4) months. There were no hospital deaths and 2 late deaths. Survival after Kawashima procedure at 5, 10 and 15 years was 90.5, 82.9 and 69.1%, respectively. It was 100% at 10 years for children 9 months old or younger at Kawashima procedure, compared with 77.0% for older children (P = 0.281). Hepatic vein incorporation was achieved in 16 patients (76.2%) at a median age of 3.3 (2.7-13.8) years and at a median interval of 2.6 (1.9-8.6) years. Survival after hepatic vein incorporation at 5, 10 and 15 years was 92.3, 83.1 and 55.4%, respectively. Pulmonary arterio-venous malformations developed in 4 patients after Kawashima procedure, which improved after hepatic vein incorporation in 3 patients. Of 4 patients who developed pulmonary arterio-venous malformations after hepatic vein incorporation, 2 patients died, and 2 patients survived. All of them had bilateral superior vena cava, and hepatic venous flow was excluded in one lung as the cause of pulmonary arterio-venous malformations.

Conclusions: Kawashima procedure could be performed with low operative risk on a patient aged less than 9 months. Despite the current early Kawashima and subsequent hepatic vein incorporation strategy, the incidence of pulmonary arterio-venous malformations did not decrease. Therefore, leaving antegrade pulmonary blood flow at Kawashima procedure is recommended.

Objectives: This study evaluates a staged selective hybrid approach for acute type A aortic dissection. The approach involves a zone 2 aortic arch replacement with debranching of the brachiocephalic trunk and left common carotid artery to create a landing zone for thoracic endovascular aortic repair. This repair is performed either pre-emptively in the subacute phase to promote remodelling or electively in the chronic phase to manage aneurysm formation.

Methods: Between January 2022 and December 2023, data from patients undergoing this approach were prospectively collected and retrospectively analyzed. The study included all patients treated with zone 2 arch replacement and debranching for acute type A aortic dissection. Preoperative characteristics, surgical outcomes and follow-up interventions, including thoracic endovascular aortic repair, were assessed.

Results: Of the 91 patients treated for acute type A aortic dissection, 25 underwent zone 2 arch replacement. No perioperative stroke or mortality occurred in this group (mean age 62.7 years, 52% male). Eleven patients (44%) underwent thoracic endovascular aortic repair during follow-up (median interval 152 days, range 38-574). Seven repairs were performed within 6 months of the initial operation. All procedures were technically successful without complications. Early imaging showed stable or reduced aortic diameters in all thoracic endovascular aortic repair patients. In the 14 patients managed conservatively, no relevant aortic growth was observed.

Conclusions: Zone 2 aortic arch replacement with debranching in acute type A aortic dissection can be performed safely. Selective pre-emptive thoracic endovascular aortic repair promoted favourable remodelling, potentially reducing the need for complex, open surgical reinterventions.

Objectives: The Ross procedure has been associated with better long-term outcomes in selected patients. Nevertheless, its complexity has limited its adoption. The aim of this study was to assess the learning curve of the Ross procedure and to evaluate the impact of new surgeons joining an experienced Ross program.

Methods: From 2011 to 2023, 673 consecutive Ross procedures were performed in adults (<69 years) at the Montreal Heart Institute. The cohort was divided into 3 groups depending on the previous experience of the operating surgeon. Safety (including mortality and major complications), efficiency (cardiopulmonary bypass and aortic cross-clamp times) and efficacy end-points (aortic regurgitation >1/4) were compared. Cumulative sum analyses were performed to evaluate mortality and major complications.

Results: There were 3 (0.45%) peri-operative mortalities. All analysed outcomes exhibited temporal trends towards improvement. Major complications decreased from 9.5% in the Early period to 1.8% in the Late (P = 0.019). Similarly, there was a statistically significant improvement in median cardiopulmonary bypass (from 203.5 min in the Early period to 163.5 in the Late, P < 0.001) and aortic cross-clamp times (from 180 min in the Early period to 148 in the Late, P < 0.001).

Conclusions: Improvement in safety, efficiency and resource utilization were observed after an initial learning period. Addition of new surgeons to an established Ross program did not negatively impact surgical outcomes. Mortality and morbidity remained low and were compared favourably with predicted risks for conventional AVR. The Ross procedure is reproducible with adequate mentorship and support to help minimize individual learning curves.

Clinical trial registration number: #2017-1974.