European Journal of Cardio-Thoracic Surgery最新文献

Objectives: Mesenteric malperfusion in acute aortic dissection remains a life-threatening complication with no standardized treatment strategy. This study aimed to describe and evaluate the outcomes of our integrated approach combining exploratory laparotomy, immediate mesenteric reperfusion, and central aortic repair.

Methods: We retrospectively reviewed patients with acute aortic dissection with a preoperative diagnosis of mesenteric malperfusion who were treated between August 2011 and November 2022. Our surgical approach was to establish cardiopulmonary bypass, followed by exploratory laparotomy with mesenteric artery flow assessment using Doppler ultrasound and direct perfusion if needed, central aortic repair, and subsequent mesenteric artery reconstruction. The primary end-point was the 30-day operative mortality.

Results: Among 217 patients with acute aortic dissection, 12 (5.5%) had mesenteric malperfusion on preoperative computed tomography. Ten patients underwent exploratory laparotomy, where Doppler ultrasonography revealed reduced mesenteric blood flow in five patients (2.3% of the total 217 patients). These patients underwent direct perfusion of the mesenteric artery via a side branch of the cardiopulmonary bypass circuit. Doppler ultrasound confirmed the restoration of mesenteric blood flow in all perfused patients. No bowel resections were required. The operative mortality in patients with mesenteric malperfusion was 20%. The causes of death were stroke (n = 1) and acute myocardial infarction (n = 1).

Conclusions: Our integrated surgical strategy combining central aortic repair with concurrent exploratory laparotomy and immediate mesenteric perfusion demonstrated technical feasibility in managing mesenteric malperfusion during aortic repair. Further prospective studies with larger cohorts are warranted to validate these findings.

Objectives: The study aimed to analyse outcomes of surgery for blood culture-negative infective endocarditis (BCNIE) and to evaluate the role of molecular biological imaging.

Methods: Patients undergoing surgery for native or prosthetic valve endocarditis from 2013 to 2022 were analysed regarding blood culture-positive infective endocarditis (BCPIE) and BCNIE. For laboratory diagnostics in BCNIE, excised valves or prostheses underwent conventional microbiological culture and fluorescence in situ hybridization combined with 16S rRNA-gene polymerase chain reaction and sequencing (FISHseq).

Results: Of 521 patients overall, we identified 473 patients (342 males, mean age 63 ± 14.4 years) with preoperative blood cultures: 396 with BCPIE (83.7%) and 77 with BCNIE (16.3%). Preoperative characteristics and operative procedures were comparable between groups and the calculated perioperative risk (EuroSCORE II) was identical (BCNIE: 12.2 ± 8.8%, BCPIE: 12.9 ± 11.9%, P = 0.788). At surgery, signs of infective endocarditis were present in 71%, missing in 18% and inconclusive in 10% of patients with BCNIE. While valve cultures alone identified pathogens in 32% of BCNIE patients, the combination with FISHseq confirmed the infective aetiology in 98% and identified causative pathogens in 52%. Overall, early mortality was similar in BCNIE (16.9%) and BCPIE (18.2%, P = 0.620), but increased in 37 BCNIE patients without pathogen identification compared to 40 patients with pathogen identification (27.0% vs 7.5%, P = 0.032).

Conclusions: Integrating FISHseq as molecular biological imaging technique into valve analysis algorithms in patients undergoing surgery for BCNIE increases diagnostic gain and potentially improves outcome.

Objectives: Safety, efficacy and durability are important considerations when selecting a bioprosthesis for aortic valve replacement (AVR). This study assessed 7-year clinical outcomes and haemodynamic performance of the Avalus bioprosthesis.

Methods: Patients indicated for surgical AVR were enrolled in this prospective, nonrandomized trial, conducted across 39 sites globally. The primary end-point of this analysis was freedom from surgical explant or percutaneous valve-in-valve reintervention due to structural valve deterioration (SVD) at 7 years of follow-up, determined using Kaplan-Meier (KM) analysis. We also evaluated a composite end-point of SVD and/or severe haemodynamic dysfunction requiring reintervention. Survival, valve-related safety events and haemodynamic performance were assessed. Deaths and safety events were adjudicated by an independent clinical events committee.

Results: A total of 1132 patients underwent surgical AVR. Mean age was 70 years; 854 patients (75%) were men. The mean STS risk of mortality was 2.0 ± 1.4%, and 659 patients (58%) had a New York Heart Association classification of I/II. One or more concomitant procedures were performed in 577 patients (51%). At 7 years, the Kaplan-Meier rate of freedom from SVD/severe haemodynamic dysfunction requiring reintervention was 1.2% (0.5-2.5%) with no cases adjudicated as SVD. The survival rate was 82.6% (79.5-85.0%). The KM event rate was 5.7% (4.3-7.7%) for reintervention, 6.3% (4.9-8.3%) for endocarditis and 0.4% (0.1-1.1%) for valve thrombosis. Mean aortic gradient, dimensionless velocity index and effective orifice area were 13.8 ± 5.9 mmHg, 0.42 ± 0.09 and 1.99 ± 0.53 cm2, respectively.

Conclusions: This analysis demonstrated excellent durability of the Avalus valve with good clinical outcomes and stable haemodynamic performance through 7 years of follow-up.

Objectives: The benefits of neoadjuvant therapy prior to surgery for patients with locally advanced oesophageal cancer have been well established by multiple trials. However, there may be socioeconomic barriers impacting equitable administration. We aim to identify whether disparities exist in the uptake of neoadjuvant therapy among patients with loco-regional oesophageal cancer.

Methods: We queried the National Cancer Database to identify patients with clinical stage II-III oesophageal cancer who underwent surgical resection (2006-2020). Logistic regression was performed to identify associations between sociodemographic factors and uptake of neoadjuvant therapy. In propensity score-matched groups, survival was evaluated using the Kaplan-Meier method.

Results: Among 19 748 clinical stage II-III patients, 85% (n = 16 781) received neoadjuvant therapy and 15% (n = 2967) underwent upfront surgery. Rates of neoadjuvant uptake increased over time. On multivariable analysis after adjusting by clinical stage, factors associated with lower rates of neoadjuvant therapy included older age (age ≥70, adjusted odds ratio 0.52; 95% confidence interval 0.47-0.57; P < 0.001), female sex (0.76; 0.69-0.85; P < 0.001), Black race (0.77; 0.63-0.94; P = 0.009), more comorbidities (0.76; 0.65-0.85; P < 0.001) and government rather than private insurance (0.84; 0.76-0.93; P < 0.001). In a propensity-matched cohort accounting for these variables, neoadjuvant treatment was associated with improved 5-year overall survival compared to upfront surgery (41.1% vs 35.4%, P < 0.001).

Conclusions: Several sociodemographic factors are associated with the delivery of neoadjuvant therapy in patients with oesophageal cancer, including age, sex, race, and insurance status. Interventions can be put into place to target vulnerable patients and ensure equitable delivery of care.

Objectives: Idiopathic subglottic stenosis (ISS) is an airway stricture between larynx and trachea, within 1 cm from the vocal cords. Resection-reconstruction present technical issues because of the need to resect the anterior portion of the cricoid cartilage, but not the posterior plate beyond which the recurrent laryngeal nerves access the vocal cords. The main surgical challenge consists of the minute airway calibre short below the cords, ensuing after the resection. We propose drill posterior cricoid plate moulding to obtain antero-posterior and lateral amplification of the laryngo-tracheal anastomosis.

Methods: This is a retrospective study of patients who underwent laryngo-tracheal resection with drill enlargement between January 2023 and June 2024. Laryngo-tracheal resection was performed according to Pearson's technique. At this point, airway calibre is gauged by endotracheal tubes of increasing size. To enlarge the air space, the inner surface of the posterior plate was moulded by drill. Breathing, complications, voice and swallowing function were recorded.

Results: Our study includes 23 consecutive patients with ISS. No mortality was described. Fifteen patients (65.2%) described voice alteration and 7 (30.4%) experienced transient swallowing impairment. The mean operative time was 94.56 (±28.72) min. All patients breathed well at discharge. Overall early success rate was excellent (no sequelae) in 7 (30.4%) patients, and good (grade A: voice/breathing changes not influencing the quality of life; grade B: abnormal voice and shortness of breath, not hindering normal activities) in 15 (65.2%). At the mean follow-up of 10.5 ± 5.5 months, definitive success was achieved.

Conclusions: This is the first study describing this technique. The results of our early experience with drill moulding of the posterior cricoid plate are promising. It is an innovative, simple, safe, and effective method for subglottic airway enlargement in ISS, resulting in low post-operative complications, and in good to excellent results.