European Journal of Cardio-Thoracic Surgery最新文献

Objectives: Single lung transplant (SLT) is an acceptable treatment modality for certain patients with end-stage lung disease. SLT occurs when two appropriate donor lungs are split between recipients ('split singles') or when one donor lung is adequate for transplant and the other lung is declined ('isolated single'). There is a paucity of literature investigating the outcomes in patients who received an isolated SLT. This study analyses the characteristics and survival outcomes of isolated SLT recipients.

Methods: The transplant database at our institution was queried for all lung transplants between 2010 and 2021. The primary outcome of survival was assessed using Kaplan-Meier curves and Cox regression modelling. Secondary outcomes were assessed using Cox regression and Fisher's exact test.

Results: Of 759 lung transplant recipients, 164 patients underwent a split SLT, and 271 patients underwent an isolated SLT. There was no significant difference when comparing most demographic characteristics between isolated SLT and split SLT patients. Isolated SLT recipients had similar overall mortality when compared to split SLT recipients (HR 0.97, 95% CI 0.72-1.33, P = 0.87). There was no difference in postoperative need for extracorporeal membrane oxygenation (P = 0.209), duration of postoperative ventilation (P = 0.408) and length of hospitalization (P = 0.443).

Conclusions: Our analysis demonstrating similar overall survival between recipients of isolated SLT and split SLT shows that a well-selected isolated donor lung can be used safely in the appropriate recipient population. This practice allows expansion of a known scarce donor lung pool and reduction of the waitlist mortality in lung transplant candidates.

Objectives: The goal was to report the outcomes and determine the effectiveness of a comprehensive organ protection strategy in total arch replacement.

Methods: A total of 350 patients who underwent total arch replacement were enrolled. Fifty-four patients underwent the comprehensive organ protection strategy with bilateral antegrade cerebral perfusion and the aortic balloon occlusion technique (comprehensive strategy group); 296 patients underwent the standard strategy with unilateral antegrade cerebral perfusion (standard strategy group). Inverse probability of treatment weighting was used to balance the baseline characteristics.

Results: After inverse probability of treatment weighting, the comprehensive strategy group had lower incidences of 30-day mortality (0.9% vs 4.9%, P = 0.002), continuous renal replacement therapy (0.6% vs 10.3%, P < 0.001), renal failure (4.6% vs 13.7%, P < 0.001), hepatic dysfunction (11.6% vs 21.1%, P = 0.001) and shorter duration of mechanical ventilation [16 (13, 31) vs 20 (14, 48) h, P = 0.011]. Multivariable logistic analysis showed that the comprehensive strategy was an independent protective factor of 30-day mortality [odds ratio (OR): 0.242, 95% confidence interval (CI): 0.068-0.867, P = 0.029], continuous renal replacement therapy (OR: 0.045, 95% CI: 0.008-0.264, P = 0.001), renal failure (OR: 0.351, 95% CI: 0.156-0.788, P = 0.011) and mechanical ventilation >20 h (OR: 0.531, 95% CI: 0.319-0.883, P = 0.015). Kaplan-Meier analysis showed that mid-term survival was comparable.

Conclusions: The comprehensive organ protection strategy might improve early survival, reduce the use of continuous renal replacement therapy, have protective effects on the kidney and shorten mechanical ventilation time in total arch replacement. This strategy might be considered a viable alternative in total arch replacement.

Objectives: This 4th report aimed to provide insights into patient characteristics, outcomes and standardized outcome ratios of patients implanted with durable Mechanical Circulatory Support across participating centres in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) registry.

Methods: All registered patients receiving durable mechanical circulatory support up to August 2024 were included. The expected number of events was predicted using penalized logistic regression. Standardized outcome ratios (Observed/Expected events) were presented in plots to assess 30-day and 1-year mortality, ischaemic stroke and major bleeding outcomes. Expected events were estimated using penalized logistic regression using demographics and comorbidities as predictors. Centres with <90% follow-up completeness were excluded from standardized outcome ratio assessment.

Results: Analysis included 6962 implants in 6408 patients (457 patients underwent repeated implants) registered in EUROMACS from 17 countries (32 centres) (median age: 58 years, 83% males, 17% Interagency Registry for Mechanically Assisted Circulatory Support class 1). Thirty-day mortality, major bleeding and ischaemic stroke probabilities were 9.6, 12.6% and 2.1%, respectively. Standardized mortality ratios showed variability between centres, ranging from 0 (95% CI 0-0) to 1.4 (95% CI 1.2-1.7). Higher standardized bleeding outcome ratios correlated with higher standardized ischaemic stroke ratio's (Spearman r: 0.56, P = 0.008).

Conclusions: Most included centres perform as expected given the demographics and comorbidities of patients. A positive correlation was found between standardized bleeding and ischaemic stroke ratios, reflecting the need of continuously monitoring of adverse events by quality improvement programs.

Objectives: We previously did a randomized clinical trial of lobectomy by VATS or thoracotomy for early-stage lung cancer and found that patients who underwent VATS had less postoperative pain and better quality of life compared with thoracotomy. VATS has since been regarded the preferred surgical method for early-stage lung cancer. It is assumed that long-term survival is not influenced by surgical approach, but this assumption primarily rests on non-randomized comparative studies. We decided to do a long-term follow-up of patients who entered our previous randomized trial.

Methods: Between 2008 and 2014 we randomly assigned 206 patients to VATS (n = 103) or anterolateral thoracotomy (n = 103) for proven or suspected early-stage NSCLC. Records from patients with NSCLC on final pathology were identified in the national electronic patient-record system and the Danish Lung Cancer Registry. Overall, disease-free, and cancer-specific survival were estimated using the Kaplan-Meier method and log-rank test was used to compare the two interventions.

Results: A total of 196 patients had NSCLC on final histopathology. Four patients were lost to follow-up and the remaining 192 were included in this follow-up study with 128 events used for overall survival analysis, 100 events for disease-free survival analysis and 79 events for cancer-specific survival analysis. VATS was used in 99 patients versus 93 by thoracotomy. Median age at time of surgery was 66 years (range 41-85 years). After a median follow-up time of 12.8 years (range 9.9-15.8 years), 33% of patients were alive. Overall, disease-free, and cancer-specific survival were not significantly different between VATS and thoracotomy: Overall survival (p = 0.29), disease-free survival (p = 0.17) and cancer-specific survival (p = 0.31).

Conclusions: We did not find any statistically significant differences in overall, disease-free, or cancer-specific survival between VATS and thoracotomy. However, larger trials with better power for survival analysis are needed to fully explore if there are differences. Alternatively, differences in survival between thoracotomy and VATS for early-stage NSCLC could be investigated by pooling survival data from two similar randomized trials that have since been published.

Objectives: This study investigates the impact of bilateral antegrade cerebral perfusion (ACP) time on outcomes in aortic arch surgery.

Methods: In total, 961 patients underwent either hemiarch (n = 385) or total arch replacement (n = 576) with bilateral ACP and moderate hypothermia management between 2006 and 2020 across 2 aortic centres. ACP time was categorized into 4 groups (≤30 min: n = 169, 30-60 min: n = 298, 60-90 min: n = 261, >90 min: n = 233). Inverse probability of treatment weighting yielded a well-balanced cohort among the 4 groups except for the cannulation site. Adjusted cubic spline and multivariable logistic analysis were performed, controlling for surgical procedure, cannulation site and cardiopulmonary bypass (CPB) time, to identify the relationship between ACP time and major in-hospital complications including mortality, stroke, acute renal failure and prolonged ventilation.

Results: There remained a significant difference in surgical procedures and CPB time in the matched cohort. The incidences of mortality and stroke did not show significant trend (P = 0.052 and 0.717, respectively). Cubic spline curves showed that odds ratios did not increase linearly for any complications with increasing ACP time. Furthermore, ACP time, even exceeding 90 min, was not associated with complication rates [mortality: odds ratio = 1.459 (0.368-6.049), P = 0.595; stroke: 0.310 (0.058-1.635), P = 0.166; renal failure: 1.744 (0.521-6.094), P = 0.374; prolonged ventilation: 1.502 (0.535-4.286), P = 0.442], whereas CPB time was associated with mortality and prolonged ventilation.

Conclusions: Even when ACP time exceeded 90 min, it was not associated with major in-hospital complications, questioning its validity as a marker for surgical insult.

Objectives: While minimally invasive surgery (MIS) is the preferred approach in patients with early-stage lung cancer, intraoperative adverse events (IOAE) may still occur. The objective of this study was to assess the impact of a dedicated preoperative planning program on adverse event occurrence.

Methods: A single-centre cross-sectional comparative study was conducted, including all patients with proven/suspected lung cancer undergoing curative MIS, prior (September 2021-October 2022) and after (November 2022-January 2024) the implementation of a preoperative planning program. The preoperative planning program consisted of a weekly assessment of upcoming surgical cases, evaluating surgical strategy, anatomical variations and anticipating surgical difficulties. Data were prospectively collected. The primary outcome was the rate of IOAE. Secondary outcomes were conversion rate, healthcare-associated adverse events and postoperative morbi-mortality.

Results: We included 553 patients, 290 without preoperative planning and 263 undergoing a preoperative planning program. The overall IOAE rate was 11.4%, significantly lower after preoperative planning (7.6% vs 14.8%, P = 0.008). The overall healthcare-associated adverse events rate was 23.2%, significantly lower after preoperative planning (17.1% vs 28.6%, P = 0.0014). There were no statistical differences before and after preoperative planning for conversion rate (8.37% vs 10.7%, P = 0.354), complication rate (33.1% vs 34.5%, P = 0.73) and 90-day mortality (0.38% vs 2.07%, P = 0.126). Preoperative planning program impacted surgical strategy in 61/263 patients (23.2%) including a change in the extent of resection in 25/263 patients (9.5%).

Conclusions: Implementation of a systematic preoperative planning program in MIS for lung cancer decreases IOAE enabling an improvement in surgical safety.