European Journal of Cardio-Thoracic Surgery最新文献

Objectives: For selecting graft sizes in valve-sparing aortic root replacement (VSARR), commissural height is often referenced as a fixed variable; however, it may be affected by the diameter of the graft implanted. Using a novel aortic root sizer, we explored whether commissural height interacts with graft size.

Methods: The novel sizer is a semi-translucent, rigid tube that is applied externally on the trimmed aortic root. It has 3 longitudinal slits with 120° orientation, which allows suspending the commissural stitches, symmetrically. The sizer is intended to identify the best graft size for a given anatomy by applying sizers of differing internal diameters, by which the quality of coaptation is inspected. Furthermore, each commissural slit is embedded with a ruler that allows measuring commissural heights. Using 5 normal porcine aortic roots with various annular diameters (23-31mm), we applied the 6 sizers in varying diameters (26, 28, 30, 32, 34 and 36 mm) on each of the root. We examined the correlations between the commissural height and baseline anatomical parameters and diameter of the sizer.

Results: The commissural height correlated positively with annular dimension (r = 0.55, P = 0.002), free-edge length (r = 0.54, P = 0.002), geometric height (r = 0.51, P = 0.004) and negatively with diameter of the sizer (r = -0.75, P = 0.002). Binary linear regression models validated that the sizer's diameter negatively correlated with the commissural height after adjustments with each of the anatomical parameters (R2, 0.83-0.87; P < 0.001 for all).

Conclusion: Commissural height is not a fixed factor, but it interacts with the native aortic root size and the dimension of the implanted graft in VSARR.

Objectives: To evaluate how well liver fibrosis markers (fibrosis-4 index, aspartate aminotransferase to platelet ratio index, and model for end-stage liver disease excluding international normalized ratio score) can predict early detection of Fontan-associated liver disease and to identify risk factors for Fontan-associated liver disease development.

Methods: This retrospective multicentre study included patients who underwent the Fontan procedure between 2004 and 2020 with at least 3 years of follow-up. Blood tests and imaging were conducted to diagnose Fontan-associated liver disease. The predictive value of these markers was assessed using receiver operating characteristic curve analysis. Risk factors for Fontan-associated liver disease development were identified using Fine-Gray subdistribution hazard analysis.

Results: This study included 137 patients. The fibrosis-4 index, measured at 2 years post-Fontan, was a strong predictor for Fontan-associated liver disease development 10 years later (area under the curve: 0.81, optimal cutoff value: 0.17, 83.1% sensitivity, and 73.0% specificity). Fine-Gray subdistribution hazard analysis shows that a fibrosis-4 index level was a key risk factor for Fontan-associated liver disease. Patients with a fibrosis-4 index >0.17 after 2 years had a higher incidence of Fontan-associated liver disease after 10 years (45.6%) than patients with fibrosis-4 index ≤0.17 (3.9%, P = 0.002). These patients also had higher pulmonary artery pressure 5 years later.

Conclusions: The fibrosis-4 may be a useful marker for early detection of Fontan-associated liver disease, which, in this study, was identified as a risk factor for the disease's development.

Clinical registration number: Kitasato University, No. B23-130; 7 February 2024.

Objectives: In an effort to maintain the technical aspects of traditional prosthetic surgical aortic valve replacement (AVR) while reducing invasiveness and facilitate options for concomitant operations, transaxillary lateral mini-thoracotomy endoscopic robotic-assisted aortic valve replacement (RAVR) has been introduced. The present data highlight the contemporary international collaborative experience.

Methods: All consecutive patients undergoing standardized RAVR across 10 international sites (1/2020-7/2024) were evaluated using a central database with 1 year follow-up.

Results: A total of 300 patients were analysed with a median predicted risk of 1.6% with aortic stenosis in 85.7%, nearly half with bicuspid valves. Biological prostheses were implanted in 220 (73.3%) with a median valve size 23 mm, 10% receiving aortic root enlargement, with 17% of all patients undergoing concomitant procedures. Median cross-clamp 120 min with no conversions to sternotomy. Median length of stay was 5 days, 4.3% with prolonged ventilation, 1.7% renal failure, 1.0% stroke and 8.3% required re-thoracotomy for evacuation of haemothorax. There were two 30-day operative mortalities (0.7%). The new permanent pacemaker rate for the full cohort was 2.6%. Of 163 patients with complete 1-year clinical and echocardiographic follow-up, mean aortic valve gradient was 10 mmHg and all but 2 patients (1.2%) had trace to no prosthetic or paravalvular insufficiency.

Conclusions: RAVR is safe and effective, providing the reproducible benefits of surgical AVR while affording a less invasive approach that permits the opportunity for concomitant procedures. For low and intermediate risk patients with aortic valve disease, RAVR is a potential reproducible alternative for patients and heart teams.

This study aims to review the anatomical variations of the right bundle branch (RBB) in normal hearts and various ventricular septal defect (VSD) subtypes through a systematic literature review. Additionally, it seeks to propose hypotheses for optimizing surgical approaches to minimize conduction disturbances during VSD closure, based on anatomical evidence. We performed a systematic literature review of peer-reviewed articles published up to October 2024, focusing on the anatomy of the cardiac conduction system and its variations in association with VSD subtypes. The review encompassed 30 articles, analysing anatomical data from over 100 reported cases of normal and VSD hearts. In the normal heart, the RBB courses posterior to Lancisi's muscle, which originates at the junction of the anterior-basal and posterior-basal limbs of the trabecular septomarginalis (TSM). In perimembranous inlet VSDs, the medial papillary muscle (MPM) does not reliably indicate the RBB's course; instead, the RBB runs close to the membranous flap, positioning it on the edge of the VSD. In perimembranous outlet VSDs, the posterior limb of the TSM covers the branching and bifurcating bundles and the base of the RBB, causing these components to deviate towards the left ventricle beneath the defect's edge, maintaining a distance of 3-5 mm. The RBB then courses intramurally, emerging at the base of the MPM. In tetralogy of Fallot cases with perimembranous outlet VSDs, the RBB consistently courses approximately 2 mm anterior to the MPM in 63-86% of cases. In normal hearts, the RBB runs posterior to Lancisi's muscle; however, in perimembranous outlet VSDs (especially ToF), the RBB typically courses about 2 mm anterior to the MPM, a critical detail to consider during VSD repair to avoid conduction system injury.

Objectives: The advantages of preoperative three-dimensional (3D) image simulations, which require enhanced computed tomography (ECT), for anatomical lung resection are well documented. However, the necessity for contrast agent presents a significant barrier for some patients. This study thus aims to evaluate the accuracy of an artificial intelligence-based 3D simulation using unenhanced computed tomography (UECT) data in comparison to ECT data.

Methods: The study enrolled 18 lung cancer patients who underwent anatomical lung resections. Utilizing the artificial intelligence software Version6.7 within the Synapse Vincent system (Fujifilm Corporation, Tokyo, Japan), automatic construction of 3D images of the bronchovascular trees was achieved using both ECT and UECT. We further assessed the accuracy of pulmonary vessel identification on UECT, and compared the calculated lung segment volumes obtained from UECT with those obtained from ECT.

Results: The comparison of accuracy to operative findings showed that ECT identified 98.9% of artery branches (PAs) and 85.7% of vein branches (PVs), while UECT identified 96.6% of PAs and 82.1% of PVs. Out of 371 PAs and 319 PVs identified on ECT, UECT failed to detect 16 PAs (4.4%) and 32 PVs (10.1%), yielding a correlation coefficient for branch detection of 0.9783 (P < 0.001). There was a significant correlation between ECT and UECT in measuring artery-oriented volumes on both the right-side segments (R = 0.8330) and the left-side segments (R = 0.8082).

Conclusions: This 3D image technique using UECT data may be comparable to that obtained with ECT data in terms of achieving lobar and partial segmental branch levels.

Objectives: Tracheobronchoplasty is an operation to treat excessive central airway collapse by stabilizing the posterior tracheal membrane. In 2020, our institution transitioned from the traditional open approach to the robotic-assisted tracheobronchoplasty in select patients. This retrospective cohort study compares postoperative complications and short-term outcomes for patients undergoing open versus robotic tracheobronchoplasty at a high-volume complex airway centre.

Methods: A retrospective review of all patients who underwent open tracheobronchoplasty (2018-2020) and robotic tracheobronchoplasty (2020-2023) was conducted.

Results: During the study period, 43 and 69 patients underwent robotic and open tracheobronchoplasty, respectively. Robotic tracheobronchoplasty had longer median operative times than open (8.4 vs 6.2 h; P ≤ 0.01). Both median intensive care unit (ICU) length of stay (1.0 vs 3.0 days, P ≤ 0.01) and hospital length of stay (5.0 vs 7.0 days, P ≤ 0.01) were shorter after robotic tracheobronchoplasty. There were no significant differences in major or minor complications, total Clavien-Dindo Score, estimated blood loss, discharge to home, and 30-day readmission. The robotic group had two reoperations during the index hospitalization and three conversions to open. There were no mortalities in either group. Short-term (3-month) functional and quality-of-life outcomes were equivalent between groups.

Conclusions: In selected patients with severe and symptomatic excessive central airway collapse, robotic tracheobronchoplasty is a safe and feasible alternative to the traditional open approach. Patients undergoing robotic tracheobronchoplasty have shorter ICU and total hospital stays with equivalent complication rates. As the robotic approach becomes more prevalent, further comparative outcomes are necessary with longer follow-up to ensure durability of the robotic-assisted repair.

Randomized controlled trials (RCTs) are the gold standard for guiding treatment recommendations. Their results reflect the average treatment effect generated in samples from a selected patient population. Observational studies may serve as external validation of RCT findings but are influenced by various biases. Conducting clinical trials in the cardiovascular field faces many challenges, including financial constraints, end point selection, including determining their value for doctors and patients, and assessment of long-term treatment effects. In addition, there is renewed debate about the optimal statistical approach for the evaluation of trial outcomes. These factors occur in parallel to efforts to develop novel clinical trial designs that address the above challenges. Pragmatic trials, for instance, may use data already collected during patient care. As an alternative to fixed sample size, two-arm designs and adaptive trial designs have been introduced, which allow for pre-specified adaptations throughout a trial. Master protocols are used to govern platform, umbrella and basket trial designs, all allowing to address more than 1 aspect at a time (e.g. the impact of multiple treatments on a single condition or a single treatment on multiple conditions). Cluster designs may allow the evaluation of new treatments into clinical routine. Here, we review strengths and limitations of conventional and novel trial designs. We provide a general description of current topics with a focus on treatment comparisons in the field of cardiovascular research.

Objectives: To examine the outcomes of patients with classical hypoplastic left heart syndrome following extracardiac total cavopulmonary connection.

Methods: We retrospectively analysed 812 cases that underwent extracardiac total cavopulmonary connection at our hospital between 1994 and 2022. With a median follow-up of 10.1 years, we compared the survival rate, Fontan-related events, liver function, postoperative haemodynamics, freedom from reintervention and exercise tolerance in 109 patients with classical hypoplastic left heart syndrome (cH group), 205 patients with heterotaxy (Hx group) and 498 patients with other univentricular conditions (O group).

Results: The survival rates (97.2% at 10 and 20 years for the cH group) and freedom rates from all Fontan-related events (81.2% and 68.1%) were similar across groups. Liver enzyme variables did not significantly differ, and liver cirrhosis was not observed. Postoperative catheter examinations showed similar Fontan pressure, end-diastolic pressure, cardiac index and pulmonary vascular resistance across groups, with a lower pulmonary artery index in the cH group. The rates of freedom from reintervention at 10 and 20 years were lower in the cH group (80.5% and 55.7%). Maximal oxygen consumption during cardiopulmonary exercise testing declined faster in the cH group (-2.5% per year) than in the O group (-0.9% per year), with no difference with the Hx group (-2.4% per year).

Conclusions: The overall survival rate of patients with classical hypoplastic left heart syndrome after Fontan procedure was comparable to that of patients with other univentricular syndromes, showing good haemodynamics and lower mid-term comorbidities. However, lower pulmonary artery index, reduced freedom from reintervention and progressive decline in exercise tolerance are remaining concerns.