European Journal of Cardio-Thoracic Surgery最新文献

Objectives: The optimal flow rate for selective antegrade cerebral perfusion during aortic arch surgery is unknown. While 10-15 ml/kg/min is generally recommended, our centre has adopted a line pressure-targeted, relatively low-flow antegrade cerebral perfusion strategy. We aimed to evaluate the effect of flow rate on neurological outcomes.

Methods: Patients without preoperative neurological deficits who underwent aortic arch surgery between January 2018 and May 2023 were enrolled. Under moderate hypothermia, an initial cerebral ischaemia period of 15-20 min was permitted. Following a brief retrograde cerebral perfusion, bilateral selective antegrade cerebral perfusion was performed using balloon-tipped perfusion catheters. The flow rate was determined using a line pressure of 200 mmHg. Risk factor analysis for postoperative permanent and temporary neurological deficits was conducted.

Results: A total of 262 patients were included. The median selective antegrade cerebral perfusion flow rate was 5.7 ml/kg/min. Permanent neurological deficits occurred in 2 patients (0.8%), while temporary neurological deficits occurred in 30 patients (11.5%). The low antegrade cerebral perfusion flow rate was not a risk factor for permanent or temporary neurological deficits. Prolonged cerebral ischaemia time was the only significant risk factor for temporary neurological deficits.

Conclusions: Under moderate hypothermia and with the assistance of retrograde cerebral perfusion, the line pressure-targeted, relatively low-flow selective antegrade cerebral perfusion strategy at our centre achieved favourable neurological outcomes. However, prolonged cerebral ischaemia time was a significant risk factor for temporary neurological deficits.

Objectives: Intensive care unit (ICU) readmission has been proposed as a metric for quality of surgical care. The current study investigated potential factors and developed a prediction model for ICU readmission in patients following oesophagectomy for cancer.

Methods: A total of 3028 patients from January 2019 to December 2022 were retrospectively collated as training cohort, with 829 patients from January 2023 to August 2023 enrolled for validation, respectively. Univariable and multivariable analyses were performed to identify potential factors after which a nomogram based on results from multivariable analysis was constructed and validated.

Results: In the training cohort, the rate of ICU readmission was 3.6% (110/3028). Readmitted patients were associated with more reoperations, higher 90-day mortality and prolonged postoperative stay (all P < 0.001). Multivariable analysis demonstrated that older age ≥75 years, neoadjuvant therapy, preoperative albuminaemia, diffusing lung capacity for carbon monoxide (DLCO)%, longer operative duration and retention of endotracheal intubation when entering ICU were independently associated with ICU readmission. Based on these results, a nomogram for predicting readmission was constructed and validated. The Hosmer-Lemeshow test showed the model in the training cohort was well calibrated (χ2 = 5.259, P = 0.73) and area under the receiver operating characteristic curve was 0.739 (95% confidence interval 0.691-0.787). Moreover, the application of the nomogram in the validation cohort showed an improved area under the receiver of 0.780 (95% confidence interval 0.703-0.857).

Conclusions: ICU readmission after oesophagectomy although uncommon (3.6%) was associated with prolonged hospitalization and significant mortality. A nomogram based on 6 variables may assist intensivists to early identifying patients at high risk of readmission.

Objectives: The Ross procedure with autograft reinforcement has been proposed as a strategy to prevent autograft failure in adults, but outcome data in children during somatic growth remain limited. We investigated long-term outcomes following an individualized autograft reinforcement protocol to evaluate survival and reintervention rates.

Methods: Between January 1995 and December 2022, 233 patients <18 years [median age: 7 (1-13) years] underwent the Ross procedure, including 60 infants (26%). Most frequently free-root autograft implantation without reinforcement was performed (n = 156, 67%). Autograft reinforcement was applied in 77 patients (33%) using either subcoronary implantation (n = 65, 28%) or external prosthetic support (n = 12, 5%). Kaplan-Meier survival estimates were used for survival and reintervention analyses. Risk factors for reintervention were identified by Cox proportional hazards regression.

Results: Reinforcement was associated with improved survival (5-year survival rates of 97.1% vs 87.0%, 10-year survival rates of 97.1% versus 86.99%, P = 0.017). No differences in autograft reintervention between the groups were found (1-year rates of 100% vs 99.4%, 5-year rates of 100%, P = 0.4852). Right ventricle-pulmonary artery (RV-PA) reintervention-free survival at 5 years was higher for homografts compared to xenografts (96.9% vs 79.4%, P < 0.001).

Conclusions: The Ross procedure in children demonstrated excellent long-term outcomes with low autograft reintervention rates in both groups. Reinforcement was associated with improved long-term survival while autograft-related reinterventions did not differ significantly between groups. Older age at Ross and homograft use correlated with lower RV-PA reintervention risk. Multicentre evaluation of reinforcement techniques is required to assess the outcome differences observed in this single-centre experience.

Objectives: Coronary endarterectomy (CE) is an adjunct to coronary artery bypass grafting (CABG) in patients with one or more diffusely diseased coronary arteries. Although associated with increased perioperative morbidity and mortality, it remains a therapeutic strategy to potentially improve late outcomes by facilitating the revascularization of an otherwise ungraftable target.

Methods: Medicare beneficiaries undergoing CABG from 2001 to 2019 were identified. Surgeon proclivity for endarterectomy was determined; surgeons were stratified by quintile of endarterectomy frequency. Overlap propensity score weighting risk-adjusted measured confounding variables. Risk-adjusted survival was compared between surgeons.

Results: 1 500 710 Medicare beneficiaries underwent isolated CABG, of whom 32 302 (2.2%) underwent concomitant CE. Surgeons were divided into never-endarterectomizers (0% frequency, 267 245 surgeries by 1839 surgeons), occasional-endarterectomizers (0-4% frequency, 1 001 310 surgeries by 2207 surgeons) and frequent-endarterectomizers (≥4% frequency, 232 155 surgeries by 756 surgeons). Beneficiaries undergoing surgery by a never-endarterectomizer had a risk-adjusted median survival of 10.05 [95% CI: 10.00, 10.09] versus 9.90 [9.86, 9.95] years in those undergoing surgery by a frequent-endarterectomizer, a difference of 1.71 [1.08, 2.37] months, P < 0.001 for risk-adjusted survival comparison. Similarly, beneficiaries undergoing surgery by an occasional-endarterectomizer had a risk-adjusted median survival of 9.94 [9.91, 9.96] versus 9.85 [9.80, 9.90] years for those undergoing surgery by a frequent-endarterectomizer, a difference of 1.05 [0.56, 1.74] months, P < 0.001 for risk-adjusted survival comparison.

Conclusions: Medicare beneficiaries undergoing CABG by never- or occasional-endarterectomizers had small early risk-adjusted survival advantages and similar late outcomes compared to those undergoing surgery by frequent-endarterectomizers. CE remains a valuable tool in selected cases; however, it may be reasonable for surgeons to adopt a never- or occasional-endarterectomy approach to CABG.

Objectives: The objective of this study was to investigate the importance of pulmonary parenchyma preservation, the results of cystotomy and the capitonnage technique and the efficacy of postoperative albendazole treatment.

Methods: A retrospective study was conducted at a single centre between 2000 and 2024, encompassing 872 consecutive patients with pulmonary hydatid cysts.

Results: Of the cases studied, 394 (45.2%) were female and 478 (54.8%) were male, with a mean age of 26.8 ± 19.7 years (range: 2-86 years). Isolated lung involvement was observed in 553 (63.4%) cases. In general, a single hydatid cyst was detected in 665 (76.3%) patients, and 466 (53.4%) of these had isolated lung involvement. In 452 cases (51.8%), only the right lung was affected, whereas 294 (33.7%) had left lung involvement, and 126 (14.5%) had bilateral lung involvement. An operation was performed in 807 (92.5%) cases. Cystotomy and capitonnage were performed in 782 (89.7%) patients. Thoracoscopic wedge resection was performed in 13 cases (1.5%), cystotomy alone in 5 cases (0.6%), lobectomy in 5 cases (0.6%) and enucleation with capitonnage in 2 cases (0.2%). Postoperative complications included atelectasis in 45 cases (5.6%), prolonged air leak in 8 cases (1.0%), empyema in 6 cases (0.7%), wound infection in 3 cases (0.4%) and bleeding in 2 cases (0.2%). Recurrence was observed in 4 (0.5%) surgically treated cases, and 1 case (0.1%) resulted in death in the postoperative period.

Conclusions: The management of pulmonary hydatid cysts with cystotomy and capitonnage is feasible in the majority of patients and results in acceptable success and complication rates. Administration of albendazole postoperatively has been shown to be an effective method of preventing recurrence.

Objectives: Virtual reality (VR) technology is increasingly employed in medical settings to provide innovative solutions for complex surgeries. In this study, we introduced and compared OpVerse, a multifunctional new VR platform developed for surgical simulations, with established software Synapse 3D to assess its efficacy in facilitating complex thoracic surgeries.

Methods: Patient-specific VR digital twin thoracic models were created based on computed tomography scans of 9 patients with large thoracic neoplasms and 4 requiring tracheobronchial reconstruction. Twelve doctors as system testers were enlisted to evaluate the usability and user acceptance of OpVerse and Synapse 3D using the System Usability Scale (SUS) and the Technology Acceptance Model; they provided qualitative feedback through interviews.

Results: OpVerse achieved higher scores than Synapse 3D in SUS (73.3 ± 14.6 vs 53.8 ± 11.6, P = 0.0006), as well as perceived usefulness (4.5 ± 0.4 vs 4.1 ± 0.5, P = 0.0134), perceived ease of use (4.2 ± 0.4 vs 3.8 ± 0.6, P = 0.0364) and attitude towards using and behavioural intention to use (4.6 ± 0.4 vs 3.6 ± 0.7, P = 0.0002) in Technology Acceptance Model, compared to Synapse 3D, indicating enhanced efficiency and user engagement with the new system. Participants favoured OpVerse for its immersive qualities, intuitive interface (particularly rotation and enhanced visual transparency effects) and ability to enhance comprehension of complex 3D anatomical structures.

Conclusions: OpVerse, our streaming VR simulation platform, enables the manipulation and visualization of patient-specific digital twin thoracic models through features such as rotation, enhanced visual transparency effects and measurement. Preliminary results suggest that OpVerse may offer advantages in terms of immersion, ease of use and understanding of 3D anatomical structures compared to Synapse 3D.

Objectives: Complex aortic arch procedures in newborns require the most optimal perfusion strategy to prevent acute kidney injury and its consequences from developing. We performed a randomized comparison of the selective anterograde cerebral perfusion (SACP) and SACP with additional distal perfusion (SACP+DP) with moderate hypothermia in a neonate piglet model to generate better insights into renal tissue-specific injury due to the different perfusion strategies in newborns.

Methods: Newborn piglets (2.5-10 kg) were randomized to undergo cross-clamp for 60 min with either SACP (n = 9) or SACP+DP (n = 9) followed by 120 min of recovery. Renal biopsies were analysed for histomorphological changes and the induction of hypoxia-related factors. Kidney injury markers were analysed in piglet serum.

Results: Histomorphological analyses of renal biopsies after 120-min recovery showed comparable glomeruli area (P = 0.06), glomerular capsule space length (P = 0.25), proximal tubules cell height (P = 0.09) and diameters of proximal tubules (P = 0.23) between SACP and SACP+DP. hypoxia-inducible factor 1α nuclear translocation, a marker for oxidative stress, was higher in the glomeruli (P < 0.01) and proximal tubules (P = 0.05) in the SACP group compared to the SACP+DP group. Serum concentrations of neutrophil gelatinase-associated lipocalin were higher in the SACP group (100.3 ± 40.8 ng/ml) compared to the SACP+DP group (67.4 ± 19.3 ng/ml, P = 0.03).

Conclusions: Our neonate piglet study demonstrated higher oxidative stress in vulnerable nephron structures in renal tissue and higher serum neutrophil gelatinase-associated lipocalin concentrations with SACP compared to SACP+DP indicating that SACP+DP is more suitable to reduce renal insult induced by complex aortic arch procedures.

Left ventricular assist device (LVAD) outflow graft obstruction (OGO) is a serious complication that often requires surgical intervention. Standard approaches involve cardiopulmonary bypass (CPB) or veno-arterial extracorporeal membrane oxygenation (vaECMO) to facilitate outflow graft clamping and shortening. We present a surgical approach to reduce the need for CPB or vaECMO for outflow graft shortening. A 25-year-old female presented for routine LVAD follow-up with reduced device flow. Computed tomography angiography revealed outflow graft obstruction due to external compression from accumulated material between the outflow graft and the bend relief, along with graft elongation. To correct this, we performed outflow graft revision and shortening using a Dacron prosthesis as a bypass from the proximal to the distal outflow graft, avoiding CPB or vaECMO. LVAD flow was immediately restored postoperatively, and the patient recovered without complications. Follow-up computed tomography angiography confirmed full resolution of the obstruction with no recurrence. Managing LVAD outflow graft obstruction is particularly challenging when accompanied by elongation. The basket-handle technique offers a safe and effective alternative to traditional methods, allowing for outflow graft shortening without CPB or vaECMO, thereby reducing procedural risks and promoting faster patient recovery.

Objectives: In an older population, infective endocarditis (IE) tends to present uniquely. In this study, we investigate the clinical presentation, microbiological profile and outcomes of IE in octogenarians.

Methods: This multicentre retrospective analysis includes 4917 consecutive patients suffering from IE. We analysed the data on octogenarians undergoing surgery due to IE. Primary outcomes were 30-day mortality and 5-year survival.

Results: We found 4625 (94.1%) were younger than 80 years old, whereas 292 patients (5.9%) were octogenarians. The median age of the non-octogenarian cohort was 65 years (54-73 years), whereas the median age of the octogenarian cohort was 82 years (81-84 years). The median EuroSCORE II was 16.5 (9.5-40.4) in the octogenarian group and 9.7 (4.4-21.5) in the non-octogenarian group (P < 0.001). There was a higher number of males in the non-octogenarian group (P < 0.001). Prosthetic valve endocarditis (P < 0.001) and pacemaker endocarditis (P < 0.001) were higher in the octogenarian group. Streptococcal infections were more frequent in octogenarians (P = 0.033), whereas a significantly higher number of non-octogenarians suffered from blood culture negative IE (P = 0.002).The rate of postoperative adverse cerebrovascular events and postoperative morbidities was comparable between the groups. The 30-day mortality was higher in the octogenarian group (P < 0.001). Survival rates at 1 and 5 years were 48% and 39%, respectively, in the octogenarian group (P < 0.001).

Conclusions: IE in the elderly is associated with a higher risk and may present with a different clinical profile. Although advanced age does play a role in the outcomes of surgery for IE, it alone should not be the sole factor to rule out surgery in this cohort.