General Thoracic and Cardiovascular Surgery最新文献

Objective(s): Due to the poor prognosis of dialysis patients, accurately predicting life expectancy after aortic stenosis surgery remains challenging, leading to potential misselection of treatment options. This study aimed to develop a prognostic model specific to dialysis patients to facilitate individualized treatment selection.

Methods: A total of 171 dialysis patients with aortic stenosis who underwent initial isolated surgical aortic valve replacement at seven cardiovascular centers in Japan between 2011 and 2021 were enrolled. The cohort was randomly divided into the training and validation cohorts in a 2:1 ratio. Risk factors contributing to mortality were identified from preoperative variables, and a prognostic model was developed using the Cox proportional hazards model.

Results: Among the 171 patients, 88 deaths occurred during the total observation period of 488.9 person-years. The cumulative overall survival rates at 1, 3, and 5 years, estimated using the Kaplan-Meier method, were 74.7%, 59.4%, and 38.7%, respectively. An optimal risk model was developed, incorporating six factors: age, serum albumin, peripheral artery disease, sex, insulin-dependent diabetes mellitus, and atrial fibrillation. The model demonstrated strong predictive accuracy, with a 5-year C-statistic of 0.723 (95% confidence interval: 0.658-0.788) and 0.656 (95% confidence interval: 0.543-0.770) in the training and validation cohorts, respectively. Calibration plots confirmed that actual survival up to 5 years was well predicted (intraclass correlation coefficient = 0.918, 95% confidence interval: 0.703-0.981).

Conclusions: The proposed model is a reliable prognostic tool for dialysis patients who underwent surgical aortic valve replacement.

Objective: To evaluate the feasibility and safety of total arch replacement with a frozen elephant trunk in patients with Stanford type B aortic dissection and an entry ≤ 10 mm distal to the left subclavian artery.

Methods: We retrospectively reviewed 40 consecutive patients who underwent either total arch replacement with a frozen elephant trunk (n = 30) or thoracic endovascular aortic repair (n = 10). The primary outcome was late all-cause mortality. Secondary outcomes included major complications, planned additional endovascular repair after total arch replacement with a frozen elephant trunk, false lumen thrombosis, and aortic remodeling.

Results: In the thoracic endovascular aortic repair group, procedure-related complications occurred, including retrograde type A dissection and one death from aortic rupture. In the total arch replacement with a frozen elephant trunk group, all deaths were unrelated to the index procedure. Planned additional endovascular repair was more frequently performed after total arch replacement with a frozen elephant trunk.

Conclusions: Total arch replacement with a frozen elephant trunk is safe for anatomically challenging type B aortic dissection with an entry near the left subclavian artery and represents a viable treatment option in this setting.

Aim: Intraoperative nerve monitoring (IONM) during esophageal cancer surgery can help to identify and preserve the recurrent laryngeal nerve (RLN). To devise a useful parameter for prediction of left vocal cord palsy (VCP), we measured the electromyographic (EMG) amplitude of the left RLN and vagus nerve (VN) using intermittent IONM.

Methods: We studied 35 consecutive patients who underwent esophagectomy with lymph node dissection around the left RLN. After lymph node dissection, the left RLN and left VN were stimulated, and the EMG amplitude was measured using IONM. The VN/RLN ratio (V/R ratio) was calculated, and the presence of left VCP, diagnosed by laryngoscopy on the first postoperative day, was compared among the patients.

Results: Ten of the 35 patients (28.6%) had left VCP. In the VCP and non-VCP groups, the left VN amplitude was 190.0 (0-1111) µV and 520.0 (120-1200) µV (P = 0.006), and the VR ratio was 0.26 (0-0.75) and 0.71 (0.24-1.0) (P < 0.001), respectively. Receiver operating characteristic curve analysis using the left VN amplitude and V/R ratio showed an area under the curve (AUC) of 0.80 with a cutoff of 354 µV, and an AUC 0.90 with a cutoff of 0.50, respectively(P = 0.05). When left VN amplitudes of < 100 μV, < 354 μV, and a V/R ratio of ≤ 0.50 were defined as left VCP, the accuracy was 80.0%, 74.2%, and 88.6%, respectively.

Conclusions: Using intermittent IONM, the V/R ratio with a cutoff value of 0.50 has the potential to be a more useful parameter for prediction of VCP after esophagectomy than EMG amplitude during VN stimulation.

Background: Aortic valve (AV) pathology in children presents a significant surgical challenge, with mid- and long-term outcomes of current techniques remaining controversial. This study evaluates our experience with aortic valve neocuspidization (AVNeo) in the pediatric population, analyzing immediate and mid-term results.

Methods: Ten children underwent AVNeo between June 2017 and August 2019. The clinical data were prospectively collected and retrospectively analyzed. The primary outcomes included failure to perform AVNeo, intraoperative conversion to the alternative technique, in-hospital mortality, and major adverse events. The secondary outcomes included aortic stenosis or regurgitation, valve-related events, reoperations, and mortality during follow-up.

Results: The median age was 9 (range: 2-17) years. AVNeo was feasible in all cases. Five children underwent previous cardiac interventions. Neocuspidization was feasible in all cases. No in-hospital mortality or significant postoperative complications occurred. Before discharge, average peak and mean pressure gradients were 13.5 mmHg and 6.5 mmHg, respectively. Aortic insufficiency was grade 0 or 1 in all cases. Seven patients required reoperation for valve dysfunction over a median follow-up of 73 months. The median time to reoperation was 62 months, with six patients undergoing mechanical valve replacement and one receiving a Ross procedure.

Conclusion: AVNeo offers excellent hemodynamic outcomes for children with AV pathology in the immediate postoperative period. However, the mid-term results revealed significant valve degeneration, necessitating reoperations in most cases. Unlike in adults, we do not consider AVNeo a definitive solution in children with AV disease. We see this technique as a valuable tool in the staged management of this congenital heart pathology.

In some patients, complete resection of malignant tumors requires phrenic nerve resection; however, this can cause postoperative phrenic nerve paralysis, leading to reduced respiratory function and limited performance of daily activities. We encountered two patients in whom the phrenic nerve was resected during surgery for a malignant anterior mediastinal tumor and subsequently reconstructed using autologous intercostal nerves to preserve the diaphragm function. Although neither patient had preoperative phrenic nerve paralysis, the phrenic nerve required resection to totally remove the encasing tumor. The third and fifth intercostal nerves were harvested and used for reconstruction because the extent of phrenic nerve resection was too long for direct suturing. Postoperative chest radiographs confirmed the preserved diaphragm function during inspiration and expiration. In patients in whom long phrenic nerve sections are resected, the use of the intercostal nerve for reconstruction may preserve phrenic nerve function.

Background: We aimed to establish the most predictive echocardiographic indicator of appropriate tightness of bilateral pulmonary artery banding (BPAB).

Methods: In part A of the study, we retrospectively analyzed the peak flow velocity (PV) and nadir flow velocity (NV) across the band and the ratio of NV to PV (velocity ratio: VR) to determine appropriate band tightness. In part B, we prospectively studied the utility of the best predictive indicators.

Results: Thirty-one patients undergoing BPAB were enrolled in part A and identified as having appropriate pulmonary blood flow (APF), high pulmonary blood flow (HPF), or low pulmonary blood flow (LPF) during the postoperative period. The areas under the receiver operating characteristic curve (AUC) for HPF were 0.92 for PV, 0.99 for NV, and 0.99 for VR; the velocity thresholds were 2.47, 1.15, and 0.45 m/sec, respectively. For LPF, the AUCs were 0.63 for PV, 0.78 for NV, and 0.81 for VR, and the velocity thresholds were 2.70, 1.59, and 0.58 m/sec, respectively; thus, VR best indicated band tightness. In part B, we performed BPAB in 34 patients, adjusting the bands to achieve VRs between 0.45 and 0.58. The prevalence of HPF was significantly lower in part B than in part A, whereas those of LPF did not differ.

Conclusion: In BPAB, we consider the optimal range of VR at banding site is between 0.45 and 0.58.

Objectives: Uniportal video-assisted thoracoscopic surgery (U-VATS) is gaining global recognition as a minimally invasive approach. However, its current status and issues in Japan remain unclear. This study aimed to assess U-VATS adoption and barriers among Japanese thoracic surgeons through a nationwide survey.

Methods: The Japanese Uniportal VATS Interest Group conducted an online survey of 3287 thoracic surgeons on the Japan Association for Chest Surgery mail list. Responses were collected from October 25 to November 30, 2024, yielding 851 valid responses (25.9%) from 497 institutions (78.0% of JACS-registered institutions).

Results: The adoption rate of U-VATS among the institutions was 42.5%. However, the proportions of thoracic surgeons who primarily performed lobectomy, segmentectomy, and wedge resection using U-VATS were 10.3%, 10.2%, and 22.0%, respectively. The main reasons for non-adoption included concerns regarding safety and surgical precision (57.2%), preference for other approaches (50.9%), and lack of instruments (48.8%). Among surgeons with no prior U-VATS experience, 34.1% were willing to adopt it. To facilitate broader adoption, respondents highlighted the need for troubleshooting resources (61.3%), high-precision surgical videos (59.0%), and hands-on training programs (51.5%).

Conclusion: Despite the relatively high institutional adoption rate, the proportion of thoracic surgeons using U-VATS as the primary approach remained low. Key barriers include concerns about safety and surgical precision, limited educational opportunities, and a lack of scientific evidence on U-VATS in Japan. To promote the wider adoption of U-VATS, it is essential to develop structured educational programs and generate evidence to ensure both safety and surgical precision.

Objective: Patients with congenital heart defects, such as tetralogy of Fallot (TOF) or right ventricular outflow tract stenosis or atresia, often require pulmonary valve replacement (PVR) decades after the primary repair. The purpose of this study was to assess the safety and efficacy of a novel synthetic hybrid fabric (SHF) for PVR in adult congenital heart disease.

Methods: SHF, consisting of bio-absorbable and non-absorbable yarns coated with cross-linked gelatin, was used in a prospective, multicenter, single-arm pivotal clinical trial involving subjects with an age range of 0-59 years. The overall study was registered in the Japan Registry of Clinical Trials (jRCT1080224691). This paper specifically presents a subgroup analysis focusing on five adult patients (aged 18-42 years) from the multicenter trial.

Results: The procedures were performed similarly to those using existing products, with no SHF-specific complications observed. The SHF material allowed surgeons to clearly observe the bioprosthetic valve annulus during suturing. None of the patients required blood transfusion or developed adverse events. At a mean follow-up of 4.5 years (range 4.0-4.9 years), no re-interventions or reoperations were needed.

Conclusion: SHF shows promise as a patch material for PVR, offering significant benefits such as clear visualization during surgery, which facilitates precise valve placement. This transparency is crucial for adults with repaired TOF, as it helps reduce surgery time and complication risks. This study suggests that SHF could be a valuable material for adult PVR, extending its potential applications beyond pediatric cardiology.

Objective: This study analyzed the changes in health-related quality of life (HRQOL) and employment status of patients undergoing lung cancer surgery in Japan.

Methods: This was a single-center, prospective study on patients who underwent lung anatomical resection. The eligible patients completed self-reported HRQOL and employment surveys at baseline and 6 and 12 months postoperatively. HRQOL was assessed using questionnaires including the European Organization for Research and Treatment of Cancer Core Quality of Life questionnaire (EORTC QLQ-C30) and EORTC QLQ and Lung Cancer module and additional social engagement and work-related stress evaluation tools.

Results: In total, 93 patients completed the baseline survey, and 80 provided survey data at 6 months postoperatively. The HRQOL scores of several factors significantly declined immediately after the surgery and then gradually improved. The EORTC global health score, which represents overall health status, returned to baseline levels at 12 months postoperatively. However, symptoms such as fatigue, dyspnea, and coughing did not return to baseline levels at 12 months postoperatively. Approximately 68% of the patients who were employed preoperatively continued to work at 12 months postoperatively.

Conclusions: Lung cancer surgery significantly affected the HRQOL and employment status of the patients within the first 6 months after surgery. For patients who decide to return to work before full recovery of QOL, we consider the need for enhanced support to assist them as they can reintegrate into work and activities of daily living.