European Journal of Cardio-Thoracic Surgery最新文献

Objectives: The Ross procedure for aortic regurgitation (AR) and abnormal aortic valve morphologies is associated with an increased risk of autograft dilatation. Autograft support may ameliorate this problem. We analysed the results for all haemodynamic lesions and the effect of autograft support.

Methods: A retrospective analysis was conducted of patients who underwent a Ross procedure at Saarland University Medical Center between December 1995 and December 2023. Three hundred and fifteen patients underwent full-root replacement with or without autograft support. Twenty-three (7%) were younger than 18 years and were excluded. The cohort was divided into 3 groups: patients with aortic stenosis (AS), AR and combined disease (CD). End points included survival, freedom from reoperation and AR and aortic root dimensions; these were compared among the 3 groups. Median follow-up was 3.6 (range 0.01-26.6) years and 95% complete.

Results: Overall, 292 adult patients [male 74%; mean age 39 years (SD: 10)] were analysed with (n = 209) or without autograft support (n = 83). Patients with AS (n = 79; 28%) were compared to those with AR (n = 77; 25%) and those with CD (n = 136; 50%). Valve morphology was unicuspid (n = 141; 48%), bicuspid (n = 109; 38%) or tricuspid (n = 42; 14%). Survival at 15 years was similar across the groups (AR 86%; AS 93%; CD 94%; P = 0.123). Freedom from autograft reoperation was 90% at 10 years (AR 80%; AS 95%; CD 92%; P = 0.009). With autograft support, it was 93% at 10 years (AR 90%; AS 93%; CD 95%; P = 0.179). Neither a unicuspid (hazard ratio 1.072; 95% confidence interval 0.34-3.43; P = 0.907) nor a bicuspid aortic valve (hazard ratio 0.102; 95% confidence interval 0.08-1.26; P = 0.102) was associated with reoperation.

Conclusions: Patients with AR and an unsupported root replacement do have an increased risk of reintervention, irrespective of aortic valve morphology. With autograft support, however, autograft stability is excellent, irrespective of the underlying lesion. Thus, the Ross procedure in its supported version can be offered to all haemodynamic types and valve morphologies.

Clinical registration: CEP 203/19.

Objectives: Surgical edge-to-edge repair has been proposed to treat tricuspid regurgitation with various aetiologies. Two techniques can be used for this repair: the 'double-orifice' and the 'clover' repairs. This study compares the clinical outcomes of these 2 techniques.

Methods: The study enrolled 258 patients who underwent tricuspid edge-to-edge repair out of 2257 tricuspid valve repairs between January 2001 and December 2021. Patients were categorized into 2 groups (double-orifice and clover repairs) and analysed using propensity score matching.

Results: The mean age of the 258 patients was 60.8 ± 12.4 years, with 190 females (73.6%) and a mean EuroScore II of 4.6 ± 5.5. Of these, 169 underwent double-orifice repair and 89 clover repair, adjusted to 118 and 66 after matching, respectively. Using the reverse Kaplan-Meier method to account for censored data, the median follow-up duration [Q1-Q3] was 169 [76-229] months. Early mortality and morbidity did not differ significantly between the groups. Survival analysis did not show statistical differences in overall mortality and late severe tricuspid regurgitation recurrence between the groups. Similarly, freedoms from late significant tricuspid stenosis (trans-tricuspid pressure gradient ≥5 mmHg) and tricuspid reoperations [8 (4.7%) in the double-orifice repair group and 2 (2.2%) in the clover repair group] were not significantly different between the groups. The sensitivity analysis, which included the inverse probability of treatment weighting analysis, produced consistent results.

Conclusions: The surgical outcomes of tricuspid edge-to-edge repair were not statistically significantly different, regardless of the repair techniques. Both methods can be valuable options for tricuspid regurgitation repair.

Objective: The aim of this study was to determine the indication and optimal timing for performing a hemiarch procedure in patients undergoing valve-sparing root replacement (VSRR).

Methods: We conducted a retrospective study on 986 patients undergoing VSRR at three tertiary care centres. Inclusion criteria were all patients undergoing elective VSRR. Exclusion criteria were age <18 years, Stanford type A dissection, dissection in the arch, total aortic arch replacement or previous aortic arch replacement. We performed propensity score matching in a 1:1 ratio. The primary end-point is a composite outcome that includes mortality, aortic arch reintervention, new aortic dissection during follow-up and cerebrovascular incidents within the first 30 days.

Results: A total of 401 patients (41%) had a hemiarch replacement, while 585 (59%) did not. Root phenotype was present in 565 (57%). The mean follow-up time was 4.7 years (SD ± 4.6). In the matched population, there was no significant difference in the 10-year freedom from the composite outcome between the non-hemiarch and hemiarch groups (87.3% vs 85.0%, P > 0.999). Similarly, no difference was found for aortic reinterventions (P = 0.13) or survival (P = 0.5). This was also true for patients with heritable thoracic aortic disease. However, in patients with a bicuspid aortic valve, the intervention rate was significantly higher in the hemiarch group (10.8% vs 0%, P = 0.016). There was no significant difference in the 30-day incidence of cerebrovascular accidents between the groups (5% vs 2.7% in the hemiarch group, P = 0.117). Only the distal ascending diameter showed a tendency with better outcome over 45 mm for the hemiarch procedure; otherwise, we found no reliable cut-off values based on ascending length, diameter-to-height index or ascending length-to-height index.

Conclusions: Our findings conclusively demonstrate that concomitant hemiarch replacement does not increase the perioperative risk in young patients undergoing VSRR. However, concomitant replacement does not seem to protect from aortic reinterventions during medium-term follow-up.

Objectives: The study's aim was to investigate the outcomes and risk factors for mortality in patients undergoing surgery for acute type A aortic dissection receiving concomitant venoarterial extracorporeal membrane oxygenation (ECMO) support.

Methods: Patients from 5 European centre who underwent surgery for acute type A aortic dissection and received perioperative venoarterial ECMO support were included. A multivariable binary logistic regression analysis was performed to identify risk factors for 30-day mortality. A receiver operating characteristic curve and restricted cubic splines were designed to investigate the association between pre-ECMO lactate peak and survival.

Results: The final cohort comprised 117 patients. Mean time on ECMO support was 3 days (interquartile range 1-7). In 36 patients (31%), successful ECMO weaning was achieved. Thirty-day mortality was 72%, leading cause for early mortality was multiorgan failure (39%). In total, 20% of patients were discharged from hospital. Pre-ECMO lactate peak [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.005-1.032], presence of preoperative shock (OR 9.47, 95% CI 1.749-98.257) and need for total arch replacement (OR 6.628, 95% CI 1.492-33.373) were identified as associates for 30-day mortality. For pre-ECMO lactate peak, the area under the curve showed an acceptable value of 0.73 and restricted cubic splines showed a significant correlation to survival (P = 0.004) with an increased risk above a lactate level of 85 mg/dl.

Conclusions: Venoarterial ECMO support may not be futile but should be well balanced against the high-risk profile in this patient cohort. The pre-ECMO lactate peak is an independent risk factor and a valid predictor of 30-day mortality.

Objectives: Previous analyses of the volume-outcome relationship have focused on short-term outcomes such as early mortality. The current study aims to update a novel statistical methodology, facilitating the evaluation of the relation between procedural volume and time-to-event outcomes such as long-term survival, using surgery for acute type A aortic dissection as an illustrative example.

Methods: This study employed an existing dataset of type A dissection outcomes, retrieved from literature. Studies were included when reporting on annual case load and long-term survival, which served as the primary outcome of interest. Individual patient data were reconstructed from the included studies, and a hazard ratio was determined per study in relation to overall survival, after which the calculated hazard ratios were incorporated in a restricted cubic-spline model, facilitating the application of the elbow method.

Results: Fifty-two studies were included (n = 14 878 patients), with a median follow-up of 5 years. One-, 3-, 5- and 10-year survival of the overall cohort were 82% [95% confidence interval (CI) 82-83%], 79% (95% CI 78-80%), 74% (95% CI 74-75%) and 60% (95% CI 59-62%), respectively. A significant non-linear volume-outcome relation for long-term survival was observed in both the unadjusted and adjusted analyses (P = 0.030 and P = 0.002), with an optimal annual case load of 32 cases/year (95% CI 31-33).

Conclusions: Based on the available data, these findings imply that the annual case volume to achieve optimal long-term survival is located near a procedural volume of 32 cases/year. After accrual of more annual procedures, long-term survival may no longer significantly improve any further.