European Journal of Cardio-Thoracic Surgery最新文献

Objectives: The aim of this study was to assess safety and efficiency of multiarterial coronary bypass grafting using bilateral internal thoracic arteries in T-graft technique performed by trainees.

Methods: Patients from January 2005 to February 2023 who had undergone multiarterial coronary bypass grafting using bilateral internal thoracic arteries in T-graft technique were analysed. Patients were divided into 2 groups based on the primary surgeon: consultant and trainees. The primary composite outcome measure was all-cause mortality and coronary reintervention after 5 years. Safety and efficiency were assessed using cumulative sum analysis.

Results: A total of 1764 patients were identified, 1114 patients (63.2%) were operated on by consultants, 650 patients (37.8%) by trainees. Mortality rates did not differ (0.8% vs 1.0%, P = 0.4). Consultants performed more distal anastomoses [3.38 (0.96) vs 3.06 (0.76); P < 0.001] and achieved more complete revascularization [n = 895 (92%)] than trainees [n = 460 (80%); P < 0.001]. In the cumulative sum analysis, safety of teaching procedures remains within the acceptable range. There was no increase in the expectation/frequency of the composite outcome measure; instead, the expected frequency decreases up to 150 operations. Duration of the operation averages decrease until the 125th operation. Performed distal anastomoses increased with the rising number of operations.

Conclusions: Our study demonstrates that training operations multiarterial coronary bypass grafting using bilateral internal thoracic arteries in T-graft technique are equally safe regardless of whether they are performed by consultants or trainees. Each trainee experiences an individual learning curve that falls within acceptable error rates and, therefore, the procedure can be safely learned directly.

Objectives: Extravascular lung water precedes deterioration of pulmonary function. Current tools to assess extravascular lung water in a setting of donor lung procurement and ex vivo lung perfusion (EVLP) are either subjective or not feasible. Therefore, a direCt Lung Ultrasound Evaluation (CLUE) has been introduced. This study reassesses the feasibility and accuracy of CLUE by measuring its correlation with lung weight, wet-to-dry ratio (W/D ratio), dynamic compliance and pulmonary vascular resistance (PVR) in a porcine model.

Methods: CLUE images, lung weight, dynamic compliance and PVR were recorded and lung samples for W/D ratio were taken before and after EVLP. CLUE score was calculated based on B-lines on images taken at each point of the lung using an established equation.

Results: Eighteen porcine lungs were included. Total median of CLUE score, lung weight, W/D ratio and PVR increased significantly, while median of dynamic compliance decreased significantly after EVLP. Total median CLUE score increased significantly in all four surfaces after EVLP with equally high CLUE scores in posterior and diaphragm lines. CLUE score demonstrated a significant strong positive correlation with lung weight (r = 0.825) and W/D ratio (r = 0.837), while CLUE's correlation with dynamic compliance and PVR was significantly moderate to strong (r = -0.669, r = 0.695, respectively).

Conclusions: CLUE technique is feasible to assess extravascular lung water in donor lungs after procurement and during EVLP. CLUE score correlated significantly with lung weight, W/D ratio, dynamic compliance and PVR. Transplant suitability of a donor lung may not solely depend on CLUE evaluation.

Objectives: Although surgery is considered the standard of care for early-stage lung cancer, there has been increased use of stereotactic radiotherapy for operable patients in recent years. Given that this modality may be perceived as a more practical treatment, we hypothesized that it might be more often delivered to patients who experience barriers to care.

Methods: The National Cancer Database (2018-2020) was queried for patients with clinical stage IA non-small cell lung cancer treated with surgery or stereotactic radiotherapy (48-60 Gy, 3-5 fractions), excluding patients with contraindications to surgery. Patients who had all the following characteristics were categorized as experiencing 'high barriers' to treatment: income below median national levels, lack of private insurance, treatment at a community facility and residence in non-metropolitan areas. Using multivariable logistic regression, the association between high barriers to treatment and stereotactic radiotherapy use was estimated.

Results: A total of 60 829 patients were included, of whom 3382 (5.6%) experienced high barriers to treatment. Among them, 13 535 (22.3%) underwent stereotactic radiotherapy and 47 294 (77.7%) underwent surgery. Overall, more patients undergoing stereotactic radiotherapy faced high barriers to treatment compared to those who received surgery (8.6% vs 4.7%, P < 0.001). Geographic region was associated with the delivery of stereotactic radiotherapy (P < 0.001). The magnitude of such association was stronger among those who faced high barriers. In multivariable analysis, experiencing high barriers to treatment remained associated with receiving stereotactic radiotherapy (OR: 1.46, 95% CI 1.35-1.58).

Conclusions: The use of stereotactic radiotherapy is more prevalent among patients facing barriers to care. Further research is needed to clarify the role of this treatment modality in early-stage lung cancer.

Objectives: In this retrospective study, we aimed to assess incidence, possible causes and clinical consequences of hypoattenuated leaflet thickening (HALT) following aortic root replacement with valved composite grafts and concomitant aortic arch repair.

Methods: Between January 2016 and December 2022, 454 patients underwent Bentall procedures with arch replacements in hypothermic circulatory arrest at the University Aortic Centre MunichLMU, Germany. Sequential postoperative ECG-gated, high-resolution computed tomography angiographies were analyzed, and the presence of HALT correlated with neurologic events and transvalvular gradients over time. Furthermore, attention was given to intraoperative hemostatic product use and postoperative anticoagulation regimes.

Results: 327 out of 454 patients were included. The follow-up period averaged to 3.27 years. 28% of the patients showed radiographic signs of HALT, which was correlated with a significantly higher incidence of transient neurological events as compared to those without (38 vs 8 events, P < 0.01). However, there were no significant differences with respect to the postoperative anticoagulation regimen or transvalvular gradients between the two groups. Only the intraoperative administration of prothrombin complex concentrate was significantly higher in patients with postoperative HALT.

Conclusions: HALT is observed in a high percentage of cases following aortic root replacement combined with complex aortic procedures. Furthermore, it is associated with an increased risk of neurological events but only a weak correlation was demonstrated with the perioperative coagulation management. While no long-term implications were noted, these findings suggest the necessity for further investigations, longer follow-up periods, and more comprehensive diagnostic approaches.

Objectives: Sarcopenia and malnutrition often occur simultaneously in adults with cardiovascular diseases. Our objective was to determine the associations of preoperative sarcopenia and malnutrition with major adverse cardiac and cerebral events (MACCE) after cardiac surgery.

Methods: We retrospectively analysed 154 consecutive patients who underwent elective cardiac surgery between January 2015 and June 2018 at two institutions in Japan. Sarcopenia and nutritional status were preoperatively assessed by bilateral psoas muscle volume index (PMVI) using CT scans and the prognostic nutritional index (PNI), respectively.

Results: The median age in the total cohort was 69 years, and 43% were women. Within 30 days after surgery, 20 patients developed in-hospital MACCE and seven patients died of any cause. Low PMVI (<72.25 cm3/m2) and low PNI (<48.15) were each independent predictors of postoperative MACCE occurrence with odds ratios (95% confidence interval) of 3.58 (1.22-10.53) and 3.73 (1.25-11.09) when adjusted for age and sex, and 3.25 (1.07-9.87) and 3.27 (1.08-9.89) when adjusted for preoperative left ventricular ejection fraction, angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker, and anticoagulant. In addition, the combination of low PMVI and low PNI conferred the highest risk of in-hospital MACCE among the four groups (i.e. the low PMVI, low PNI, low PMVI + low PNI and neither low PMVI nor low PNI groups).

Conclusions: Preoperative low PMVI and low PNI were respectively associated with 30-day in-hospital MACCE occurrence after cardiac surgery. Notably, coexistence of these reductions further enhanced the risk of postoperative MACCE.

Objectives: Cardiac surgery remains one of the most gender-imbalanced surgical specialties. Women constitute 6-11% of the North American workforce, while other regional data are scarce. Despite the acknowledged under-representation of women in cardiac surgery globally and evidence that surgeon-patient gender concordance enhances postoperative outcomes, precise figures remain poorly defined. Herein, we provide the 1st global quantification of women cardiac surgeons (WCS) and explore correlates of workforce diversity.

Methods: The Cardiothoracic Surgery Network database was queried for cardiac surgeons within each country and cross-validated with external sources. Profile pronouns and the genderize.io application determined surgeon sex. Data were stratified by country, geographical region and national income group, and correlation analyses with socioeconomic and gender parity metrics were performed.

Results: Women constitute 8.0% (1178/14 651) of the international cardiac surgical workforce, with a median of 0.00 WCS per million women (interquartile range: 0.00-0.09). North America (11.4%) and Europe (10.3%) lead regional representation, while East Asia (2.9%) and the Middle East (1.7%) rank lowest. High-income countries (9.9%) have double the proportion of WCS as low- and middle-income countries (4.8%), with a notable absence among low-income countries. Female representation correlates with Gross National Income per capita (τ = 0.39), the Global Gender Gap Index (τ = 0.26) and health expenditure (τ = 0.26).

Conclusions: Improving female representation in cardiac surgery is essential to advancing social justice and overall patient care. Yet, WCS remain a minority worldwide, with the most pronounced disparities in low- and middle-income countries and regions with low Gross National Income, Global Gender Gap Index and health expenditure. Confronting these inequities will require targeted mentorship efforts and addressing country-specific entry barriers, necessitating further research into the unique factors influencing women in low- and middle-income countries.

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.