European Journal of Cardio-Thoracic Surgery最新文献

Objectives: Mechanical support options for children and small adolescents in low cardiac output syndrome or cardiogenic shock are often still limited to veno arterial extracorporeal life support and subsequent left or biventricular assist device implantation. We aim to transfer mechanical support options with microaxial flow pump devices from the adult to the paediatric population and therefore aim to identify patient selection criteria and evaluate possible support duration and bridging modalities in a paediatric Impella registry.

Methods: This is a single-centre retrospective observational study including every patient <18 years presenting with cardiogenic shock and treated with an Impella device only from 2022 to 2024.

Results: The study cohort included 6 patients with a median age of 12 (3-17 years), median weight of 35.6 kg (12-115 kg) and a median body surface area (BSA) of 1.2 m2 (0.57-2.4 m2). Intermacs levels were 2 (4 patients) and 3 (2 patients). Heart failure aetiologies were dilative cardiomyopathy (3 patients), myocarditis (1 patient), acute rejection after cardiac transplantation (1 patient) and low cardiac output syndrome after complex endocarditis surgery (1 patient). The implanted devices were an Impella 2.5 [1], Impella CP [2] and Impella 5.5 [3]. Median support duration was 7 (4-45) days. Two patients could be bridged to recovery. Three patients were bridged to an left ventricular assist device, and 1 patient was bridged to cardiac transplantation. We observed no mortality and no neurological complications.

Conclusions: Left ventricular unloading in cardiogenic shock in children and adolescents using an Impella is feasible and safe. In older patients allowing for implantation of larger devices, a longer support duration is possible.

Objectives: This study retrospectively analysed the effect of the number of resected pulmonary segments on surgical outcomes of patients with non-small-cell lung cancer undergoing anatomical pulmonary resection.

Methods: We examined patients who underwent lobectomy or segmentectomy for non-small-cell lung cancer between January 2016 and June 2021. We compared the surgical outcomes between the ≤3 segment group (group A) and the ≥4 segment group (group B). Lung functions were evaluated by comparing the preoperative and 6-month postoperative periods. Comprehensive preoperative status, including osteoporosis, sarcopenia and lung function, was incorporated into the propensity score matching analysis.

Results: Propensity score matching for 420 patients yielded 310 for evaluation (1:1 matching), with a median follow-up of 57.6 months. Fifty-four patients (17.5%) died (17 from lung cancer and 37 from other diseases), and 50 patients (16.1%) experienced cancer recurrence. The 2 groups had no significant differences in surgical outcomes, including operation time, blood loss and postoperative complications. However, group B showed the worst reduction in vital capacity and forced expiratory volume in 1 s (all P < 0.05). Additionally, there were no significant differences in cancer recurrence or lung cancer mortality between the groups, although group B was significantly associated with increased deaths from other causes (P = 0.007, Gray's test; adjusted subdistribution hazard ratio 2.392; 95% confidence interval 1.170-5.167). Subgroup analyses revealed adverse effect modification in male patients regarding non-cancer-related deaths (P-value for interaction = 0.044).

Conclusions: The ≥4 segment group exhibited poorer postoperative pulmonary function and more deaths from other causes, indicating the need for careful postoperative management.

Clinical prediction models are statistical models or machine learning algorithms that combine information on a set of predictor variables about an individual to estimate their risk of a given clinical outcome. It is crucial to ensure that the sample size of the data used to develop or validate a clinical prediction model is large enough. If the data are inadequate, developed models can be unstable and estimates of predictive performance imprecise. This can lead to models that are unfit or even harmful for clinical practice. Recently, there have been a series of sample size formulae developed to estimate the minimum required sample size for prediction model development or external validation. The aim of this statistical primer is to provide an overview of these criteria, describe what information is required to make the calculations and illustrate their implementation through worked examples. The software that is available to implement the sample size criteria is reviewed, and code is provided for all the worked examples.

Objectives: The question whether minimally invasive extracorporeal circulation (MiECC) represents the optimal perfusion strategy in cardiac surgery remains unanswered. We sought to systematically review the entire literature and thoroughly address the impact of MiECC versus conventional cardiopulmonary bypass (cCPB) on adverse clinical outcomes after cardiac surgery.

Methods: We searched PubMed, Scopus and Cochrane databases for appropriate articles as well as conference proceedings from major congresses up to 31 August 2024. All randomized controlled trials (RCTs) that fulfilled pre-defined MiECC criteria were included in the analysis. The primary outcome was mortality, while morbidity and transfusion requirements were secondary outcomes. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool. All studies meeting the outcomes of interest of this systematic review were eligible for synthesis.

Results: Of the 738 records identified, 36 RCTs were included in the meta-analysis with a total of 4849 patients. MiECC was associated with significantly reduced mortality [odds ratio (OR) 0.66; 95% confidence interval (CI) 0.53-0.81; P = 0.0002; I2 = 0%] as well as risk of postoperative myocardial infarction (OR 0.42; 95% CI 0.26-0.68; P = 0.002; I2 = 0%) and cerebrovascular events (OR 0.55; 95% CI 0.37-0.80; P = 0.007; I2 = 0%). Moreover, MiECC reduced RBC transfusion requirements, blood loss and rate of re-exploration for bleeding together with incidence of atrial fibrillation. This resulted in significantly reduced duration of mechanical ventilation, ICU and hospital stay.

Conclusions: This meta-analysis provides robust evidence for the beneficial effect of MiECC in reducing postoperative morbidity and mortality after cardiac surgery and prompts for a wider adoption of this technology.

Objectives: The Ross procedure allows the replacement of a diseased aortic valve with a living valvular substitute and provides a normal life span. However, progressive autograft dilatation and subsequent neoaortic valve regurgitation leading to reoperations remain major drawbacks. Our objective was to assess the long-term outcomes of our modified Ross technique with pulmonary autograft reinforcement in a Valsalva Dacron graft.

Methods: Data from all patients who underwent a modified Ross procedure in our institution between 2003 and 2020 were reviewed retrospectively.

Results: One hundred eighty-nine patients were included in this study. Median age at surgery was 31 years [interquartile range (IQR) 22.5-38.7]. Patients were predominantly male (74.1%) and with bicuspid aortic valve (90.5%). Indication for surgery was pure aortic regurgitation in 40.2%, pure aortic stenosis in 30.7%, mixed lesion in 26.5% and prosthetic valve failure in 2.7%. Median cardiopulmonary bypass and aortic cross-clamping times were 135 (IQR 120-171.5) and 114 (IQR 101.5-1423.5) min, respectively Three perioperative deaths occurred (1.6%). Median follow-up was 8.6 years (IQR 5.3-11.5); three late deaths occurred. Overall survival rate was 96.6% at both 5 and 10 years. Ten patients underwent 11 late autograft reinterventions. Freedom from autograft reoperation was 95.8% and 95.0% at 5 and 10 years, respectively. The main indication for autograft reoperation was neoaortic regurgitation due to cusp prolapse. With death as a competing outcome, we observed a trend towards an increased risk for autograft reintervention in patients with pure preoperative aortic regurgitation (sub-hazard ratio 4.47, P = 0.057; 95% confidence interval 0.95-20.9).

Conclusions: The modified Ross procedure with inclusion of the pulmonary autograft using a Valsalva Dacron graft showed excellent results at 10 years.

Objectives: It has been suggested that long-term risk for incident cancer is increased in patients operated with cardiopulmonary bypass. We compared the risk for incident cancer and cancer-specific death between patients undergoing coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass.

Methods: All patients without a history of cancer undergoing first-time CABG in Sweden during 1997-2020 were included in a nationwide population-based observational cohort study. Individual patient data from the SWEDEHEART registry and 4 other mandatory national registries were merged. The incidence of new cancer was compared between patients operated with or without cardiopulmonary bypass using multivariable Cox proportional hazards regression models adjusted for baseline characteristics, co-morbidities, socioeconomic factors and time of surgery. A propensity score-matched analysis with 3735 well-balanced pairs was also performed.

Results: A total of 81 097 patients undergoing CABG with (n = 77 345) and without cardiopulmonary bypass (n = 3752) were included. Median follow-up was 8.2 (interquartile range 4.0-13.2) years. The crude event rates were 2.71 and 2.68 per 100 person-years in the patients operated with and without cardiopulmonary bypass, respectively. There was no difference in the adjusted risk for cancer between the groups [adjusted hazard ratio 0.95 (95% confidence interval; CI 0.90-1.01)] or in the risk for cancer-specific death between the groups [adjusted hazard ratio 0.99 (95% CI 0.89-1.09)]. The propensity score-matched analysis showed similar results [hazard ratio 0.96 (95% CI 0.89-1.04) and 0.99 (95% CI 0.85-1.13)], respectively.

Conclusions: Cardiopulmonary bypass is not associated with an increased risk of incident cancer or cancer-specific mortality in patients undergoing CABG.

The management of thoraco-abdominal aortic aneurysms remains challenging, particularly in patients considered unsuitable for conventional endovascular procedures due to unfavourable anatomy or unfit for traditional open surgical approaches due to comorbidities. In response to these limitations, a novel hybrid prosthesis has emerged as an alternative designed to reduce invasiveness, avoid aortic cross-clamping and avoid extracorporeal circulation. The Thoracoflo® (Terumo Aortic, Glasgow, UK) has been developed to bridge the gap between open and endovascular techniques, especially for patients with connective tissue disorders and individuals with complex anatomical challenges. In this paper, we present the use of the Thoracoflo device via a thoraco-phreno-laparotomy, offering an alternative to the previously employed medial laparotomy.