General Thoracic and Cardiovascular Surgery最新文献

Objectives: Left atrial (LA) and left ventricular (LV) venting during open-heart surgery is essential for myocardial protection, maintaining a bloodless field, and facilitating air removal. However, catheter malposition and inadequate venting are not uncommon because of limited visibility. Although transesophageal echocardiography (TEE) can assist in catheter monitoring, TEE-guided management strategies remain underreported. This study aimed to characterize catheter-related issues and describe effective troubleshooting approaches.

Methods: We retrospectively analyzed intraoperative TEE findings in 304 patients who underwent open-heart surgery at Kochi University Hospital, including 200 with LV venting and 104 with LA venting. TEE records of catheter-related events and corrective maneuvers were reviewed, and challenges in TEE assessment were identified.

Results: No catheter-related injuries were observed. In the LV group, TEE identified failure of ventricular entry (n = 5), impingement on papillary muscles or the apex (n = 18), and catheter-induced mitral regurgitation (n = 11). Residual air was frequently localized distant from the catheter tip. In the LA group, misplacement into pulmonary veins (n = 9) or the left atrial appendage (LAA) (n = 2) was noted. Venting was ineffective in cases of acute LV distension during antegrade cardioplegia or due to Thebesian venous return. In some cases, deep catheter placement resulted in incomplete drainage of the right-sided LA.

Conclusions: Both LA and LV venting have distinct pitfalls. TEE facilitates identification and correction of catheter-related problems, but structured training in TEE assessment is essential to optimize outcomes.

Objective: Postintubation tracheal stenosis (PITS) results from ischemic damage and granulation tissue formation due to prolonged high cuff pressure. Surgical resection and reconstruction is the gold standard treatment, with success rates exceeding 94%. Tritube with flow-controlled ventilation (FCV) offers advantages such as a better surgical field, uninterrupted ventilation, and reduced contamination risk. Traditionally, crossfield intubation has been the standard approach worldwide. This study aims to compare the short-term surgical outcomes of Tritube FCV and crossfield intubation in PITS patients.

Methods: This retrospective study included 131 patients who underwent surgery for PITS between 2015 and 2025. Tritube FCV was used in 22 patients (Group 1), while crossfield intubation was used in 109 patients (Group 2).

Results: Mean age and gender distribution were similar between groups. Group 1 had significantly more comorbidities (p = 0.005). Surgery duration, hospital stay, and incision type showed no significant differences. The resected segment was longer in Group 1, though not statistically significant (p = 0.073). Continuous suture technique was more commonly used in Group 1 (p < 0.001). Rates of restenosis and postoperative complications were similar. Overall survival was significantly better in the Tritube FCV group (p = 0.004).

Conclusions: Despite having more preoperative risk factors, patients in the Tritube FCV group had comparable surgical outcomes and significantly better overall survival. Tritube FCV appears to be a safe and effective alternative, even in high-risk PITS patients.

Objective: In minimally invasive surgeries such as video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS), unexpected complications may necessitate conversion to thoracotomy. This study aimed to compare the rates, causes, and implications of conversion to thoracotomy between VATS and RATS.

Methods: We retrospectively reviewed data from 1135 patients who underwent anatomical lung resection for primary lung cancer via VATS (n = 580) or RATS (n = 555) from 2011 to 2024. Conversion causes were categorized using the Vascular, Anatomy, Lymph node, Technical (VALT) system. Perioperative outcomes and independent predictors of conversion were analyzed via multivariate logistic regression.

Results: The overall conversion rate was significantly lower in the RATS group than in the VATS group (2.0% vs. 7.8%, p < 0.001). RATS was associated with fewer anatomical (0.9% vs. 3.1%, p = 0.010) and lymph node-related (0.2% vs. 2.6%, p < 0.001), with no significant difference in vascular-related conversions (0.9% vs. 2.1%, p = 0.142). Multivariate analysis identified age ≥ 75 year, clinical T2-4, and N1-2 stage as independent risk factors, while RATS use was protective. Emergency conversions were uncommon in both groups, whereas RATS appeared advantageous in technically demanding settings.

Conclusions: RATS significantly reduces the risk of conversion, particularly in anatomically or nodally complex cases, without increasing vascular complications.

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.