European Journal of Cardio-Thoracic Surgery最新文献

Objectives: The effect of previous cardiac surgery (PCS) on the outcomes of acute type A aortic dissection (ATAAD) repair remains controversial. This study compared the primary outcome (in-hospital mortality) and secondary outcomes (postoperative complications and post-discharge mortality/aortic reoperation rates up to 5 years) of patients who underwent ATAAD repair with and without PCS through a nationwide cohort analysis.

Methods: We used Taiwan's National Health Insurance Research Database to enroll patients who underwent ATAAD repair with and without PCS (94 and 4532, respectively) between 1 July 2004 and 31 March 2017. A 1:4 propensity score matching (PSM) was used to create well-balanced PCS (n = 74) and non-PCS (n = 296) groups. Results before and after PSM were aligned to determine the role of PCS in primary and secondary outcomes.

Results: Before PSM, the PCS group was older and had more comorbidities, including diabetes mellitus, heart failure, atrial fibrillation and malignancy, but less stroke history than the non-PCS group. More patients in the PCS group received coronary artery bypass grafting during the repair than in the non-PCS group. The PCS group had a higher in-hospital mortality than the non-PCS group. After PSM, the in-hospital mortality was similar between the 2 groups (27.0% vs 26.7%; P = 0.953). For patients who survived to discharge, the all-cause mortality up to 5 years for PCS and non-PCS groups were 29.7% and 18.4% (P = 0.015) before and 29.6% and 23.1% (P = 0.313) after PSM, respectively. The 2 groups had similar aortic reoperation rates up to 5 years before (13.5% vs 11.7%; P = 0.727) and after PSM (13.8% vs 11.6%; P = 0.776).

Conclusions: Patients with PCS who underwent ATAAD repair showed higher in-hospital and long-term mortality rates than those without PCS when not controlled for confounding factors. However, the disparity disappeared after PSM, indicating that worse outcomes might be due to its old age and different perioperative characteristics.

Objectives: Our aim was to investigate the incidence and risk factors for prolonged air leak (PAL) in patients undergoing minimally invasive single-port pulmonary segmentectomy.

Methods: A retrospective analysis of all patients undergoing uniportal segmentectomy in our department from March 2015 to September 2023 was performed. Univariable, multivariable logistic regression analyses and machine learning were used to investigate risk factors for PAL (>5 days).

Results: In total, 575 segmentectomies were performed using uniportal video-assisted thoracoscopic surgery. In total, 333 patients (57.9%) were men, and the mean age was 64.8 years. PAL occurred in 88 patients (15.3%). Length of stay and duration of chest drainage were 8.6 (SD: 4.86) and 10.6 (SD: 8.12) days in the subgroup with PAL, compared to 3.6 (SD: 2.25) and 2.0 (SD: 1.3) days in the subgroup without air leak (P < 0.0001). Multivariable analysis revealed that upper lobe location, lower body mass index (BMI), an additional wedge resection on another segment and hypertension were associated with increased risk of PAL. Machine learning was used to develop models that predicted the occurrence of PAL with an accuracy of 70%. The first model detected the following parameters as significant: resection of segment 2, diabetes, inhalers, and squamous cell carcinoma. The second model recognized diffusing capacity of the lungs for carbon monoxide (DLCO%), pack-years, forced expiratory volume in one second (FEV1%) and surgery time, respectively.

Conclusions: Low BMI, DLCO% or FEV1% values, increased pack-years, inhalers, diabetes, hypertension, histology of primary lung cancer, longer surgery time, an additional wedge resection, segment 2 removal and upper lobe surgery were identified as risk factors for PAL.

Objectives: To define morphologic risk constellations during valve-sparing aortic root replacement (VSARR) for aortic valves with paracommissural fenestrations.

Methods: Patients from the multicentre prospective intention-to-treat VSARR-registry German Aortic Root Repair Registry (GEARR) were screened for paracommissural cusp fenestrations. We studied a combined end-point of residual aortic regurgitation (rAR) on post-cardiopulmonary bypass (CPB) transesophageal echocardiography (TEE), mid-term progress of rAR (transthoracic echocardiography) and aortic valve replacement for AR.

Results: Of a total of 762 registry patients (operated 2016-2024), 145 were identified with ≥1 paracommissural cusp fenestration. Eighteen patients (12%) were not treated as planned but underwent composite valved graft (CVG) implantation. Mean follow-up time was 3 years. Upon post-CPB TEE, rAR grade 1 or 2 were present in 44 (33%) and 3 (2%) patients. 50% of patients with fenestrations in more than one cusp showed early progression of rAR. At 3 years, freedom from the combined end-point was 78% (99% CI 74-79%) for the complete study cohort. Patients with a maximum free margin length difference of <5 mm, reflecting balanced root anatomy with respect to sinus and cusp sizes, had a significantly better outcome than those with ≥5 mm: at 3 years, freedom from the combined end-point was 86% (99% CI 80-91%) vs 41% (99% CI 38-46%, P = 0.011). Outcome was worst for patients with cusp prolapse and a free margin length difference of >5 mm (30% vs 70%, P = 0.018).

Conclusions: Fenestrations in more than one cusp, inhomogeneities of cusp-free margin lengths, and additional prolapse are associated with inferior outcome after VSARR for valves with paracommissural fenestrations.

Clinical trial registration number: DRKS00007872.

Objectives: 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: Smoking is a modifiable risk factors for lung resections but to what extent preoperative smoking cessation reduces that risk remains unclear. The study hypothesis was that potential benefit of smoking cessation can be assessed measuring the risk difference between active and former smokers in a large cohort of patients.

Methods: Data were extracted from the French Society of Thoracic and Cardiovascular Surgeons (SFCTCV) database. The study cohort was composed of patients who underwent lung resection for cancer from January 2002 to December 2020 and for which information on smoking status was available. The risk of overall and specific postoperative complications according to smoking status was defined by logistic regression models and results were presented in terms of OR and relative 95% confidence intervals adjusted for confounding factors.

Results: Out of the 7204 analysed patients, at the time of surgery, 20.2% were active smokers, 60.7% ex-smokers and 19.1% never smokers. As compared to former smokers, active smokers experienced a higher rate of respiratory complications (OR 1.5, CI 1.2-1.7) and infections (OR 1.6, CI 1.3-1.9). Postoperative atelectasis was significantly reduced in former smoker (3%) as compared to active smokers (6.9%, p < 0.01). In active smokers, the risk was related to the level of exposure, being higher for smokers of more than 40 P/Y.

Conclusions: After lung surgery, active smokers experience an higher risk of respiratory complications, infections and prolonged air leak as compared to former smokers. This risk seems to be related to the level of exposure.

Objectives: The aim of the study was to evaluate the outcomes of aortic valve repair techniques using cusp patch-plasty with CardioCel.

Methods: Between September 2014 and June 2021, a total of 167 patients underwent aortic valve reconstruction using cusp repair. In all patients CardioCel patch was used exclusively. An isolated cusp repair was performed in 117 patients (70%), while 50 patients with concomitant aortopathy needed a combined valve and root repair. Seventy-two patients (43%) presented with tricuspid valve. The mean age of the entire cohort was 54.3 ± 12.3 years , 143 patients being males.

Results: Early (30-day/in-hospital) mortality was 0.6%. The survival at 2, 4, and 6 years was 98.8%, 96.8%, and 95.7%, respectively. During the mean follow-up of 4.2 ± 1.7 years (resulting in 697 patient-years), a relevant aortic insufficiency occurred in 10 patients (8 of them presenting with bicuspid valve). All the patients underwent a valve replacement, resulting in a 7.8 ± 2.5% cumulative risk of aortic valve reoperation and/or insufficiency ≥3+ at 6 years. The causes of reoperation were cusp tear at the suture line, progressive valve pathology, endocarditis, and unknown in 4, 4, 1, and 1, respectively. Degeneration and/or calcification of the CardioCel has not been observed.

Conclusions: The intermediate results of aortic cusp repair using CardioCel are good. Anatomo-pathology of the aortic valve and quality of the cusps seem to be main reason of repair failure. Further investigations are needed to assess the long-term durability of CardioCel patch-plasty as an alternative to biological valve replacement in specific aortic valve pathologies.

Objectives: Infective endocarditis (IE) with intervalvular fibrosa (IVF) 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 IVF reconstruction in the setting of acute IE at two national referral centres from April 2014 to November 2023. Patients were divided into two groups, regarding the extend of surgery at the aortic root level: non-ROOT (Commando) and ROOT (Root-Commando: commando with root replacement).

Results: Seventy-eight patients were included; thirty (38.5%) in ROOT group and 48 (61.5%) non-ROOT. 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: 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, 5,470 patients with BOV (n = 3,947, 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 call-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.