European Journal of Cardio-Thoracic Surgery最新文献

The heart team (HT) approach, recommended for managing cardiovascular diseases, emphasizes multidisciplinary collaboration. Despite its potential benefits, evidence on its effectiveness and implementation is varied and sparse. This review assesses the HT approach's impact on patient outcomes and care delivery in cardiovascular care. A systematic review was conducted across MEDLINE, EMBASE, PubMed, Cochrane and Google Scholar up to July 2023, focusing on studies that implemented an HT approach in coronary and heart valve disease management. Exclusion criteria included non-human studies, case reports and studies not focusing on HT outcomes. From 6270 identified articles, 20 met the inclusion criteria. These studies demonstrated significant variability in HT composition and organization, coupled with a lack of standardized metrics for evaluating clinical outcomes and the impact of the HT. Significant variability was observed in HT composition, with 13 of the 20 studies did not utilize structured templates, those that did demonstrated more consistent decision-making. In mitral valve interventions, HTs were linked to reduced in-hospital mortality and improved long-term survival (5-year survival probability of 0.74 vs 0.70, P = 0.04). In aortic valve interventions, 80% of patients underwent tailored valve procedures following HT evaluation. The HT approach in cardiovascular care demonstrates improved patient outcomes, particularly in specialized interventions for mitral and aortic valve diseases and coronary artery disease management. Despite these positive findings, the variability in HT implementation and the need for standardized outcome metrics call for further advances to optimize this collaborative care model.

Objectives: In patients with interstitial lung disease (ILD), the diaphragm typically rises as the lungs chronically shrink. However, the grade of restriction differs in each patient. It is currently unknown, how disparities between actual and predicted recipient total lung capacity (TLC), impact changes in lung function parameters and long-term outcomes following lung transplantation (LTx).

Methods: This retrospective study included 170 LTx for the patients with ILD performed in a European high-volume LTx center between 09/2011 and 12/2022. The preoperative median ratio of recipient actual to predicted (a/p) TLC was 0.55. Patients were stratified into two groups: low a/p TLC ratio group, corresponding to a more restricted chest cavity (<0.55: n = 85), and high a/p TLC ratio group, corresponding to a more preserved chest cavity (≥0.55: n = 85). Perioperative and long-term outcomes, including lung function and overall survival, were analysed.

Results: Between the two groups, tracheostomy and reintubation rates, length of mechanical ventilation, ICU-stay and hospital-stay were not significantly different. Although lung function measurements obtained early after LTx were better in the high a/p TLC ratio group, no significant differences were observed in the long term. Five-year overall survival was not significantly different between the two groups.

Conclusions: Although LTx for ILD patients with a restricted chest is considered technically more challenging, the perioperative course is similar to ILD patients with a preserved chest. In addition, no significant differences were observed between both groups in long-term lung function and overall survival, suggesting an improvement in chest wall compliance.

Objectives: Antiplatelet therapy increases the risk of bleeding and transfusion in patients undergoing extracorporeal circulation. Reduced goal-directed anticoagulation is a personalized approach to reduce the anticoagulation based on a lower targeted activated clotting time. We assessed whether reduced goal-directed anticoagulation using optimized extracorporeal circulation alleviates the risk of severe bleeding in patients treated by dual antiplatelet therapy (DAPT) compared to aspirin alone during coronary artery bypass grafting (CABG).

Methods: A total of 2275 patients undergoing CABG from 2002 to 2022 were selected after propensity matching from a retrospective cohort of 3018 patients. Patients treated with a combination of aspirin and prasugrel or ticagrelor or clopidogrel were included in the DAPT group (n = 1111). Patients treated with aspirin alone (ASA) constituted the control group (n = 1164). Optimized extracorporeal circulation was conducted under reduced systemic anticoagulation with a target activated clotting time 250 s. Severe bleeding was assessed using 3 validated scores of bleeding: UDPB, E-CABG, and BARC-4.

Results: While all scores showed low ranges of severe bleeding (<6%), they were significantly higher after DAPT compared to ASA (P values for UDPB, E-CABG, and BARC-4 at 0.016, 0.006, and 0.063, respectively). Higher maximal activated clotting time was associated with higher rate of transfusion (P < 0.001) and bleeding (P < 0.001) after multivariate adjustment. Mortality was 1.24% in DAPT vs 0.94% in ASA group (P = NS), whereas cardiac death, myocardial infarction, stroke, and transient ischaemic attack were low (<1%) and similar between groups.

Conclusions: Despite higher bleeding under DAPT compared to ASA alone, optimized extracorporeal circulation with reduced goal-directed anticoagulation alleviated severe bleeding which remained low in patients undergoing CABG.

Objectives: This study aimed to assess survival rates and the causes of both early and late mortality in patients with Stanford type B acute aortic dissection (TBAAD).

Methods: A retrospective analysis was conducted on all consecutive patients presenting with TBAAD from 2000 to 2018 at a single tertiary care centre. The primary end-point was early (<3 months) and late (>3 months) survival following TBAAD, with causes of both early and late mortality evaluated.

Results: A total of 274 patients, with a mean age of 64 ± 13 years, were included. Among these, 155 patients (57%) presented with uncomplicated TBAAD, including 52 (19%) identified as high-risk, and 119 patients (43%) had complicated TBAAD. Early aorta-related mortality occurred in 9 patients (3.3%), all within the complicated TBAAD group. The median follow-up period for the entire cohort was 8.5 years [95% confidence interval (CI) 7.6-11.2]. Long-term survival was significantly higher in patients with uncomplicated TBAAD compared to those with complicated TBAAD (P < 0.001). Both complicated and high-risk uncomplicated TBAAD cases required significantly more interventions in the chronic phase (>3 months) compared to uncomplicated TBAAD cases [hazard ratio (HR) 9.8, 95% CI 6.4-15.4, P < 0.001; HR 3.3, 95% CI 2.1-5.1, P < 0.001).

Conclusions: Complicated TBAAD presents the greatest risk for aorta-related mortality and interventions. Patients with high-risk uncomplicated TBAAD are also notable for an increased rate of aorta-related mortality and interventions. Thorough evaluation of clinical and anatomical characteristics is essential for determining the optimal therapeutic approach.

Central message: Underrepresentation of women in surgical specialties persists, especially in academic leadership roles. Efforts to better understand disparities and support women cardiothoracic surgeons are ongoing.