European Journal of Cardio-Thoracic Surgery最新文献

Objectives: Coronary artery bypass grafting (CABG) is often performed alongside type A aortic dissection (TAAD) repair. However, the association between concomitant CABG and the clinical outcomes of TAAD repair remains uncertain.

Methods: This study included 1002 consecutive TAAD patients who underwent total aortic arch replacement (TAR) with frozen elephant trunk from June 2019 to January 2024. Concomitant CABG during TAR and frozen elephant trunk was performed under 3 conditions: planned CABG for coronary ostial involvement, planned CABG for coronary artery disease and rescue CABG. Patients who underwent rescue CABG (N = 42) were compared with those who had planned CABG (N = 218) and those who did not undergo CABG (non-CABG: N = 742). Logistic regression, Kaplan-Meier and Cox regression analyses were employed.

Results: Operative mortality rate was 2.40%; 42 (4.19%) patients underwent rescue CABG. The rescue CABG group had the highest operative mortality (23.81%) among the 3 groups (P < 0.001). Rescue CABG was associated with increased operative mortality compared with non-CABG [odds ratio: 18.96, 95% confidence interval (CI) 7.32-49.08, P < 0.001], whereas planned CABG was not significant. The median follow-up period was 24.80 (interquartile range 11.73-39.10) months. Kaplan-Meier analysis demonstrated poorer overall survival in the rescue CABG group (log-rank P-value < 0.001). Rescue CABG significantly increased all-cause late mortality compared with non-CABG (hazard ratio 13.69, 95% CI 6.53-28.70, P < 0.001), while planned CABG did not. The 2-year cumulative incidence of graft occlusion among CABG patients was 24.54%.

Conclusions: Rescue CABG is significantly associated with increased operative and all-cause mortality in patients undergoing TAR and frozen elephant trunk for TAAD. Further research is required to identify the causes of rescue CABG.

Objectives: The primary objective was to externally validate EuroSCORE I and II in surgically treated endocarditis patients. The secondary objective was to assess the predictive performance of both models across sex, redo surgery, age, and urgency.

Methods: Data were retrieved from the Netherlands Heart Registration. All patients with infective endocarditis who underwent cardiac surgery between 2013 and 2021 were included. Predictive performance was assessed by discrimination (area under the curve), calibration (calibration-in-the-large and calibration plots), and a decision curve analysis.

Results: Two thousand five hundred and sixty-nine cases were included. Overall postoperative 30-day mortality was 10.2%. The area under the curve was 0.73 for EuroSCORE I and 0.72 for EuroSCORE II. Both models overpredict postoperative 30-day mortality, with observed-to-expected ratios of 0.37 and 0.69. EuroSCORE I overpredicts mortality across the full range, whereas EuroSCORE II overpredicts mortality only above a 20% predicted probability. We observed no significant differences in predictive performance across sex, redo surgery, or age. Discriminative capacity of EuroSCORE II was poor in emergency surgeries.

Conclusions: Both EuroSCORE models demonstrate acceptable discriminative capacity in IE patients. EuroSCORE I consistently overestimates mortality and should not be utilized in endocarditis patients. EuroSCORE II can be used in IE patients up to a predicted probability of approximately 20%, regardless of sex, redo surgery, or age. Beyond this point, the predicted mortality risk should be halved to approach the true mortality risk. EuroSCORE II should not be used for risk prediction in emergency endocarditis surgeries and patients should not be withheld from indicated surgical treatment solely based on high EuroSCOREs.

A narrowed patent aortic lumen (<25 mm) represents a challenging scenario frequently observed during thoraco-abdominal and abdominal aortic pathologies involving the visceral vessels. The paper aims to describe the characteristics of a novel tapered-shape inner-branched custom-made stent-graft designed to specifically address the narrowed patent aortic lumen and its applicability in a wider spectrum of aortic scenarios at the reno-visceral segment.

Objectives: Prone positioning (PP) has benefits in patients with acute respiratory distress syndrome. The objective of this study was to compare the effects and complications of PP in obese versus non-obese patients with moderate-to-severe acute respiratory distress syndrome after cardiothoracic surgery.

Methods: We retrospectively analysed a database established in 2014-2021 in an intensive care unit. The primary end point was the change in PaO2/FiO2 induced by PP. Secondary end points included pressure ulcers, mediastinitis and intensive care unit mortality. The groups with versus without obesity (body mass index >30 kg/m2) were compared, and a mixed linear model was built to identify factors associated with the PaO2/FiO2 change.

Results: 81 patients with acute respiratory distress syndrome (36 with vs 45 without obesity) and 189 PP sessions were included. PP duration was 17.2 ± 4.5 h in obese and 18.0 ± 3.8 h in non-obese patients (P = 0.23). Mean number of sessions was 2.6 ± 1.4 in obese and 2.1 ± 1.3 in non-obese patients (P = 0.10). Median PaO2/FiO2 increase after the 1st PP session was 75.0% [14.5-123.0] and 72% [15.5-130.5] in the groups with versus without obesity (P = 0.67). Stage 3/4 pressure ulcers were more common in the obese group (44.4% vs 22.2%; P = 0.03) and occurred chiefly on the face. No significant differences between the obese and non-obese groups were found for mediastinitis (16.7% vs 8.9%, P = 0.33) or intensive care unit mortality (22% vs 20%, P = 0.81).

Conclusions: Improvement of oxygenation was not statistically different between patients with versus without obesity. Pressure ulcers were more common in the obese group, whereas mediastinitis was not. No patient experienced wound dehiscence.

Objectives: The appropriate antithrombotic regimen after a Fontan operation is yet to be elucidated. Hence, this study aimed to compare the incidence of thromboembolic events in patients with and without receiving warfarin for thromboprophylaxis in a large post-Fontan population.

Methods: This retrospective cohort study used data from the Diagnosis Procedure Combination database in Japan between April 2011 and March 2022. We identified all patients who underwent a Fontan operation and excluded those who were born before 2010, died during the hospitalization or received mechanical heart replacement. Propensity score overlap weighting was performed between patients discharged with warfarin (with or without aspirin) and the control group (only aspirin or neither aspirin nor warfarin). Cox and Fine-Gray hazards models compared thromboembolic and bleeding events.

Results: We identified 2007 eligible patients, including 1670 warfarin users and 337 non-users. The mean follow-up duration was 2.1 years. The crude proportions of thromboembolic events were 3.0% and 3.0% and those of bleeding events were 0.4% and 0.3% in the warfarin and control groups, respectively. There was no significant difference in thromboembolic events between the groups (sub-distribution hazard ratio: 0.77; 95% confidence interval 0.39-1.51; P = 0.45) or bleeding events (sub-distribution hazard ratio: 0.78; 95% confidence interval 0.09-7.03; P = 0.83).

Conclusions: Warfarin use at discharge after a Fontan operation may not be necessary for thromboembolism prophylaxis in paediatric patients, based on large-scale real-world data, with a mean postoperative follow-up duration of 2.1 years. There is room for further studies to reconsider routine warfarin use in patients post-Fontan operation.

Objectives: The transaxillary concept for minimally invasive cardiac surgery-aortic valve replacement is a new and versatile approach with nearly no visible scars. Due to its novelty, available data in literature are scarce. This study reports clinical outcomes of 1000 consecutive patients.

Methods: Between 2019 and 2023, 4394 patients underwent elective isolated aortic valve procedures, with 2958 (67.5%) transcatheter aortic valve implantation's and 1436 patients surgical aortic valve replacement's (32.5%). Within this period, 1st consecutive 1000 transaxillary isolated minimally invasive cardiac surgery-aortic valve replacement were enrolled. Endocarditis, redo's or combined procedures were excluded. Mean age was 67.9 ± 8.3 years, STS-PROM 1.39 ± 2.89% and EuroScore II 1.65 ± 1.12%.

Results: Use of the transaxillary access increased from 18.7% (2019) to 97.8% (2023). Mean procedure time was 127 ± 31 min, and average cross-clamp time was 43 ± 14 min. Used prostheses were rapid deployment (81.1%), sutured biologic (14.5%) or sutured mechanical valves (4.1%). Conversion rate was 1.9%. No patient died intraoperatively. Thirty-day major adverse cardiac and cerebrovascular event was 1.9% including 0.9% mortality, 0.8% perioperative stroke and 0.6% myocardial infarction. Multivariate factors for major adverse cardiac and cerebrovascular event are intraoperative conversion [OR 1.08 (1.00-1.16); P = 0.04], intraoperative transfusions [OR 1.21 (1.07-1.38); P < 0.01] and respiratory failure [OR 1.39 (1.30-1.49); P < 0.01]. Corresponding factors for mortality are diabetes on insulin [OR 1.02 (1.00-1.04); P = 0.03], pure aortic regurgitation for primary indication [OR 1.03 (1.01-1.05); P < 0.01], intraoperative conversion [OR 1.11 (1.07-1.16); P < 0.01], renal failure [OR 1.08 (1.05-1.10); P < 0.01] and respiratory failure [OR 1.22 (1.17-1.26); P < 0.01].

Conclusions: Transaxillary minimally invasive cardiac surgery-aortic valve replacement is a safe, effective and cosmetically convincing method for surgical aortic valve replacement, having the potential for >95.0% minimally invasive cardiac surgery rate in selected patients.

Objectives: This study investigates our enhanced recovery after minimally invasive cardiac surgery program "enhanced recovery after minimally invasive cardiac surgery" (ERMICS) following a 'Zero ICU' concept compared to standard-of-care treatment in terms of safety and clinical efficacy.

Methods: All patients who underwent minimally invasive mitral valve surgery for primary severe mitral valve regurgitation between 2021 and 2023 were included. Propensity score matching (2:1) was performed between patients who received standard-of-care treatment and those who underwent ERMICS. Patients treated with the ERMICS approach were transferred to the peripheral ward instead of the intensive care unit on the day of surgery (Zero ICU). Separate primary end-points were safety (mortality, stroke), postoperative ventilation time and hospital length of stay.

Results: A total of 611 patients (566 standard of care vs 45 ERMICS) were included in the study. After 2:1 matching, the cohort comprised 135 patients (90 standard of care vs 45 ERMICS) and were well balanced in terms of pre- and intraoperative variables. Thirty-day mortality was 0% in both groups. Postoperative ventilation time [P = 0.018, odds ratio (OR) < 0.01, confidence interval (CI) < 0.001], postoperative pain (P = 0.005, OR = 0.36, CI 0.18-0.74) and hospital length of stay (P = 0.049, OR = 0.28, CI 0.08-0.98) was significantly lower in ERMICS patients, while postoperative complications did not differ.

Conclusions: Our ERMICS 'Zero ICU' concept is safe and leads to significantly shorter postoperative ventilation time and hospital length of stay for patients undergoing minimally invasive mitral valve surgery for primary severe mitral valve regurgitation.

Objectives: Right ventricular-to-pulmonary artery coupling has been associated with outcomes in mitral regurgitation treated by transcatheter approaches. We evaluated right ventricular-to-pulmonary artery coupling as a predictor of survival and postoperative length of hospital stay (LOS) in patients with mitral regurgitation undergoing mitral valve surgery.

Methods: In this retrospective analysis (median follow-up: 5.8 years), right ventricular-to-pulmonary artery coupling was quantified as the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) using transthoracic echocardiography. Receiver operating characteristic curve analysis was used to determine the optimum cut-point of TAPSE/PASP to predict all-cause mortality, and the study population was dichotomized according to this value. The primary end point was all-cause mortality. A secondary end point of LOS was also assessed.

Results: Out of 142 patients (median age: 67, female: 49%), 35 showed impaired coupling at baseline (TAPSE/PASP ≤0.35). Patients with TAPSE/PASP ≤0.35 had higher absolute mortality (37% vs 8%, P < 0.001) and longer LOS (7 days vs 9 days, P = 0.04). Kaplan-Meier analysis revealed lower survival in patients with TAPSE/PASP ≤0.35 (log-rank: P < 0.0001). In multivariable Cox regression, TAPSE/PASP ≤0.35 was the most significant predictor of all-cause mortality (hazard ratio: 3.69, 95% confidence interval 1.31-10.1, P = 0.011), alongside chronic obstructive pulmonary disease and estimated glomerular filtration rate. TAPSE/PASP ≤0.35 was associated with significantly increased LOS (β: 4.6, 95% confidence interval 0.66-8.5, P = 0.022) alongside left ventricular ejection fraction, mitral valve replacement and urgent operation.

Conclusions: In mitral regurgitation patients undergoing mitral valve surgery, TAPSE/PASP ≤0.35 is associated with increased mortality and LOS. Further validation is indicated in larger, prospective cohorts.