General Thoracic and Cardiovascular Surgery最新文献

Objective: Transapical-transcatheter aortic valve replacement is one of the main interventions indicated for patients where access via peripheral vessels is challenging. However, there have been no reports on the long-term outcomes of this intervention. Here, we report the long-term outcomes of this intervention.

Methods: Among 178 patients who underwent transapical-transcatheter aortic valve replacement between October 2009 and July 2023, 173 patients who underwent this intervention for native aortic stenosis were included in this study, and early and long-term results were evaluated.

Results: The mean age was 82.4 ± 6.4 years, 52.6% were women, mean body area was 1.46 ± 0.17 m², and the Society of Thoracic Surgeons Predicted Risk of Mortality was 11.2 ± 9.9%. In-hospital mortality was observed in three patients (1.7%). Mean follow-up duration was 4.3 ± 2.8 years, and the survival rates at 1-, 3-, 5-, and 8-years were 84.9%, 67.1%, 47.0%, and 22.1%, respectively. Freedom from cardiovascular mortality at 1, 3, 5, and 8-years was 92.9%, 86.1%, 75.8%, and 53.5%, respectively. The freedom from disabling stroke rates at 1, 3, 5, and 8-years were 95.0%, 92.4%, 92.4%, and 90.8%, respectively. Multivariate analysis revealed that male (Hazard Ratio 1.85, 95%Confidence Interval 1.27-2.70, p = 0.0012) and hemodialysis (Hazard Ratio 1.64, 95%Confidence Interval 1.00-2.67, p = 0.049) were significant poor prognosis factors.

Conclusions: Long-term outcomes of transapical-transcatheter aortic valve replacement were satisfactory. Despite the variety of available approaches, the role of transapical-transcatheter aortic valve replacement, which has low vascular impact, has not been completely lost.

Introduction and objective: Indication for mitral valve (MV) surgery in asymptomatic mitral regurgitation (MR) patients with preserved ejection fraction (EF) remains unclear. This study aims to identify risk factors of adverse clinical outcomes in asymptomatic MR patients with preserved EF for early indication of MV surgery.

Methods: 3 databases were systematically searched to include studies with asymptomatic MR patients with preserved EF. Risk factors of adverse clinical outcomes (composite outcome of MACE and MV surgery indication), mortality, and left ventricular dysfunction (LVD) are pooled with a meta-analysis of random effect model.

Results: A total of 39 observational studies with 9135 asymptomatic moderate to severe MR patients are included. We identified 21 statistically significant risk factors for adverse outcomes. Increased natriuretic peptide, presence of atrial fibrillation, LV GLS > 20%, LVEDD > 35 mm, LVESD > 22 mm, and LAVI > 55 ml/mm², ERO > 55mm², and regurgitation volume > 60 ml (HR 2.21, 2.07, 4.23, 2.98, 4.05, 1.84, 4.02, 3.30, respectively; p-value < 0.05; I² 0-87%) are associated with greater risk of adverse clinical outcome. Risk factors associated with postoperative LVD are the increase of LVEDD, LVESD, and RVSP. Risk factors associated with mortality are increasing STS score and LV GLS.

Conclusion: Several clinical parameters and risk factors can be used to stratify asymptomatic MR patients with preserved ejection fraction who could benefit from early indication for MV surgery.

Pulmonary segmentectomy for small non-palpable tumors, such as lung cancer or pulmonary metastasis, is challenging owing to possible insufficient surgical margins. Particularly, extensive segmentectomy beyond the second lobe may be required to obtain a sufficient surgical margin for a tumor adjacent to an incomplete interlobar fissure. Radiofrequency identification (RFID) marking systems have proven beneficial for detecting small lung tumors during surgery. Herein, we present two representative cases of complex segmentectomy (left-side video-assisted thoracoscopic extended S⁸ + S⁹ segmentectomy and left-side robot-assisted thoracoscopic extended S¹⁺² b + c segmentectomy) for small lung cancer adjacent to an incomplete interlobar fissure. Extensive segmentectomy was avoided, and preservation of lung parenchyma was feasible using an RFID system. The patients could undergo segmentectomy safely with a sufficient surgical margin. In conclusion, an RFID system facilitates secure and safe precise segmentectomy while minimizing the resected pulmonary volume.

Introduction: Transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) are established interventions for alleviating symptoms and enhancing survival in individuals with severe aortic stenosis (AS). However, the long-term outcomes and incidence of reintervention associated with TAVI and SAVR remain uncertain.

Methods: We conducted a systematic review and meta-analysis to compare the incidence of reintervention in TAVI versus SAVR. PubMed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs). Risk ratios (RR) and 95% confidence intervals (CI) were pooled with a random-effects model. A p-value < 0.05 was considered statistically significant.

Results: Nine RCTs were included, with 5144 (50.9%) patients randomized to TAVI. Compared with SAVR, TAVI increased reinterventions (RR 1.89; 95% CI 1.29-2.76; p < 0.01) and the need for pacemakers (RR 1.91; 95% CI 1.49-2.45; p < 0.01). In addition, TAVI significantly reduced the incidence of new-onset atrial fibrillation (RR 0.43; 95% CI 0.32- 0.59; p < 0.01). There were no significant differences in all-cause mortality (RR 1.04; 95% CI 0.92-1.16; p = 0.55), cardiovascular mortality (RR 1.04; 95% CI 0.94-1.17; p = 0.44), stroke (RR 0.97; 95% CI 0.80-1.17; p = 0.76), endocarditis (RR 0.96; 95% CI 0.70-1.33; p = 0.82), and myocardial infarction (RR 1.06; 95% CI 0.79-1.41; p = 0.72) between groups.

Conclusions: In patients with severe AS, TAVI significantly increased the incidence of reinterventions and the need for pacemakers as compared with SAVR.

Background: While the effect of pre-transplant weight on patient outcomes following heart transplantation (HTx) has previously been studied, data regarding the impact of dynamic weight change prior to HTx are extremely limited.

Objectives: We sought to elucidate the interaction between HTx listing weight and weight change while waitlisted, and explore how that interaction impacts post-HTx survival in a continuous manner.

Methods: Adult patients listed for HTx from 1987 to 2020 were identified from UNOS database. Three-dimensional restricted cubic spline analysis explored post-HTx survival relative to both changes in BMI/weight and BMI at time of HTx listing. Continuous predictor variables were analyzed with Cox proportional hazards method.

Results: 9,628 included patients underwent HTx. Median recipient age was 55 [IQR 46-62] years, and 21% were females. 53% of patients lost while 47% gained weight on the waitlist. Median BMI (27.6 kg/m² [24.3-31.3] vs. 27.4 kg/m² [24.2-30.9], paired p < 0.001) and weight (84.8 kg [73.0-98.0] kg vs. 84.4 kg [72.6-96.6], p < 0.001) were similar at listing and transplant. One-year survival was 89.3%. Weight loss over 3 BMI points or 10 kg was associated with higher hazard of death irrespective of listing BMI. In non-obese patients, some weight gain (1-4 BMI points or 5-15 kg) was associated with improved survival. In cachectic patients (BMI < 18.5), failure to gain weight was associated with worse survival.

Conclusions: Impact of weight change varies depending on listing BMI. While a survival benefit is seen in non-obese patients who gain some weight, significant weight loss is associated with poorer survival.

Objective: The effect of one-inflow and two-inflow coronary surgical revascularization techniques inclosing skeletonized double mammary artery (BIMA) as T-graft on outcome is studied.

Methods: Early ad mid-term outcome of complete BIMA revascularization (C-T-BIMA) versus left-sided BIMA with right-sided aorto-coronary bypass (L-T-BIMA + R-CABG) is quantified and analyzed by multivariate logistic regression, Cox-regression, and Kaplan-Meier analysis in a series of 204 consecutive patients treated for triple-vessel coronary disease (3v-CAD).

Results: The L-T-BIMA + R-CABG technique (n = 104) enables higher number of total (4.02 ± 0.87 vs. 3.71 ± 0.69, p = 0.015) and right-sided (1.21 ± 0.43 vs. 1.02 ± 0.32, p = 0.001) coronary anastomoses, improves total bypass flow (125.88 ± 92.41 vs. 82.50 ± 49.26 ml, p < 0.0001) and bypass flow/anastomosis (31.83 ± 23.9 vs.22.77 ± 14.23, p = 0.001), and enhances completeness of revascularization (84% vs.69%, p = 0.014) compared to C-T-BIMA strategy (n = 100), respectively. Although the incidence of MACCE was comparable in the two groups (8% vs.1.2%, p = 0.055), the progression of functional mitral regurgitation (FMR) was significantly lower after L-T-BIMA + R-CABG, then after C-T-BIMA (47% vs.64%, p = 0.017). The use of C-T-BIMA-technique (HR = 4.2, p = 0.01) and preoperative RCA occlusion (HR = 3.006, p = 0.023) predicted FMR progression, whereas L-T-Graft + R-CABG technique protected against it (X² = 14.04, p < 0.0001) independent of the anatomic and clinical complexity (Syntax score I: HR = 16.2, p = 0.156, Syntax score II: HR = 1.901, p = 0.751), of early- (0.96% vs.2%, p = 0.617) and mid-term mortality (5.8% vs.4%, p = 0.748) when compared to C-T-BIMA, respectively.

Conclusions: The two-inflow coronary revascularization by L-T-BIMA + R-CABG better protects against FMR progression without increasing MACCE and mortality. Older patients with RCA occlusion and reduced LV-EF benefit most from the two-inflow L-T-BIMA + R-CABG technique. Younger 3v-CAD patients with normal LV-EF can preferentially be managed with the one-inflow C-T-BIMA; however, long-term outcome remains to be revealed.

Objectives: Transaxillary access is the most popular alternative to transfemoral transcatheter aortic valve replacement. Although left transaxillary access is generally preferred, right transaxillary transcatheter aortic valve replacement could be challenging because of the opposing axillary artery and aortic curvatures, which may warrant procedural modifications to improve alignment. Our aim is to compare our single center's outcomes for left and right transaxillary access groups and to evaluate procedural modifications for facilitating right transaxillary transcatheter aortic valve replacement.

Methods: Patient characteristics and outcomes were compared for consecutive left or right axillary TAVRs performed from 6/2016 to 6/2022 with SAPIEN 3. The effects of our previously reported "flip-n-flex" technique on procedural efficiency and new conduction disturbances were subanalyzed in the right axillary group.

Results: Right and left transaxillary transcatheter aortic valve replacement were performed in 25 (18 with the "flip-n-flex" technique) and 26 patients, respectively. There were no significant differences between patient characteristics or outcomes. Right axillary subanalysis showed the "flip-n-flex" technique group had significantly shorter fluoroscopy times (21.2 ± 6.2 vs 29.6 ± 12.4 min, p = 0.03) and a trend towards less permanent pacemaker implantation (6.3% vs. 42.9%, p = 0.07) compared to the group without "flip-n-flex".

Conclusions: In our study, despite anatomical challenges, right transaxillary transcatheter aortic valve replacement is comparable to left access. The "flip-n-flex" technique advances right transaxillary as an appealing access for patients with few options.

We report on the "Triple-FP technique," a novel surgical approach for secondary spontaneous pneumothoraces, which combines a free pericardial fat pad, fibrin glue, and polyglycolic acid sheets. In our experience with 13 patients suffering from secondary spontaneous pneumothoraces, this method effectively prevented postoperative air leaks and re-operations. The technique includes the following steps: (1) harvesting free pericardial fat; (2) suturing around the lung parenchymal defect with the needles and thread left outside the thoracic cavity; (3) ensuring contact between the mediastinal pleural side of the fat and the lung; (4) applying fibrin glue to both the lung and fat before suturing; (5) securing the fat to the lung via the suture thread, reinforced with fibrin glue; and (6) stabilization with polyglycolic acid sheets and additional fibrin glue. This innovative technique is a reliable and effective treatment strategy for secondary spontaneous pneumothoraces, especially for patients with fragile lung tissue.

Background: Thoracic endometriosis syndrome gives rise to various clinical and radiological manifestations. We reviewed the records of patients operated for intrathoracic migration of abdominal viscera through a diaphragmatic hernia secondary to thoracic endometriosis.

Methods: We retrospectively reviewed the single-center prospective collected database of all patients operated for thoracic endometriosis during the twenty years. All cases in which an abdominal organ was found to be herniated into the thoracic cavity were retrieved. Clinical and pathological data are presented and analyzed.

Results: Twenty women of median age 36 (range 25-58) years were operated for endometriosis-related diaphragmatic hernia. The hernia was diagnosed concomitantly with endometriosis-related pneumothorax in 13 cases and during the exploration of catamenial thoracic pain in seven cases. There were 18 cases on the right side and two cases on the left side. The median diameter of the hernia was 8 cm (2.5-20 cm). In seventeen cases, the hernia was repaired by direct suture, and in three cases a heterologous prosthesis was positioned. At follow-up, two patients had an episode of recurrent pneumothorax.

Conclusions: Diaphragmatic hernia should be ruled out in the presence of endometriosis-related pneumothorax or catamenial thoracic pain. Surgery is indicated to make a pathological diagnosis, restore anatomy, and prevent recurrence in patients presenting with pneumothorax.