Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery最新文献

Despite efforts to improve donor heart allocation policies, geographic disparities, logistical challenges and patient criteria limit organ availability. However, recent surgical innovations offer potential solutions. These include partial heart transplantation and xenotransplantation. Partial heart transplantation is a new procedure with the potential to address several clinical challenges in treating congenital heart defects. Cardiac xenotransplantation involves the transplantation of genetically modified porcine hearts into humans, offering a potential solution to the shortage of donor organs. Although immunologic barriers and ethical concerns remain, ongoing research aims to mitigate the risks and optimize outcomes, providing hope for patients in need. These innovative surgical approaches offer promising avenues for addressing the critical shortage of donor hearts and with ongoing research, may hold the potential to revolutionize heart transplantation, and improve outcomes for patients facing terminal heart failure.

Objective: To assess the midterm outcomes and feasibility of using 3-dimensional total endoscopic surgery (3D TES) for complete correction of partial atrioventricular septal defect (PAVSD) in children.

Methods: A descriptive study from January 2018 to June 2024 involved 20 patients with PAVSD who underwent surgical repair using 3D TES. The average patient age and average weight were 9.1 (range: 4 to 15) years and 25.02 kg, respectively. Mitral valve regurgitation was classified as mild in 2 patients, moderate in 12, and severe in 6, whereas tricuspid valve regurgitation was mild in 13 patients and moderate in 7.

Results: Peripheral circulation was established in all patients. Cardiopulmonary bypass and aortic cross-clamp times were 86.2 min and 142.2 min, respectively. The mechanical ventilation time averaged 4.9 h. Postoperative echocardiography included complete closure of the atrial septal defect, with mild mitral valve regurgitation in 16 patients and no regurgitation in 4. Tricuspid valve regurgitation was mild in 11 patients, and 9 patients had no regurgitation. During an average postoperative follow-up period of 3.35 years, there were no mortalities or cases requiring reoperation.

Conclusions: The 3D TES demonstrates feasibility, safety, and efficacy in treating PAVSD in children, with apparent aesthetic advantages.

Objective: The aim of the current study was to analyze the clinical and surgical outcomes of patients undergoing isolated tricuspid valve surgery (ITVS) from the available literature. It currently remains uncertain whether arrested heart (AH) surgery has superior postoperative outcomes over beating heart (BH) for ITVS.

Methods: A systematic review and meta-analysis were conducted by searching PubMed, ScienceDirect, Scopus, DOAJ, SciELO, and Cochrane databases from 2000 until November 2024. The protocol was registered with the International Prospective Register of Systematic Reviews under the PROSPERO registration number CRD42024622618.

Results: A total of 22 studies met the inclusion criteria. These studies were published between 2012 and 2023 and included a combined total of 1,627 patients, with 1,053 in the BH group and 574 in the AH group. The present analysis showed that patients undergoing BH surgery were generally more comorbid and more frequently underwent minimally invasive procedures as compared with patients undergoing AH surgery. The BH and AH groups reported no significant differences in postoperative outcomes. At follow-up, BH was associated with higher recurrent >2+ tricuspid regurgitation rates (P = 0.048), but this did not affect late survival (hazard ratio [HR] = 0.90, 95% confidence interval [CI]: 0.68 to 1.19, P = 0.457) or reintervention for TV (HR = 1.18, 95% CI: 0.61 to 2.29, P = 0.622) rates.

Conclusions: A consensus between BH and AH for ITVS is still lacking. However, BH ITVS procedures appear to be the preferred surgeon choice for higher-risk patients. At follow-up, the BH group showed higher rates of recurrent tricuspid regurgitation >2+, without affecting late survival or rates of TV reintervention.

Objective: To develop a holistic measure of congenital heart center performance, we created a composite "textbook outcome" (TO) for the Fontan operation using postoperative endpoints. We hypothesized that achieving the TO would have a positive prognostic and financial impact.

Methods: This was a single-center study of primary Fontan operations from 2005 to 2022. TO was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, chylothorax, >75th percentile length of stay, and >75th percentile mechanical ventilation duration. Multivariable logistic regression and Kaplan-Meier survival analysis were used to assess statistical significance.

Results: Overall, 49% of patients (97 of 198) met the TO. Patients who failed to achieve the TO were more likely to have a dominant right ventricle, moderate-severe regurgitation of the systemic atrioventricular valve, and higher pulmonary vascular resistance. In the multivariable analysis, the presence of pulmonary artery (PA) stenosis, higher mean PA pressure, and Norwood as the index operation were independently associated with a lower likelihood of achieving the TO. However, a history of atrial septostomy prior to Fontan was independently associated with a 3-fold higher likelihood of achieving the TO. Patients who met the TO acquired lower median direct hospital costs ($40,800 vs $80,400, P < 0.001) and had higher long-term survival (log rank, P = 0.027).

Conclusions: Fontan TO achievement is associated with increased long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality alone becomes a less-sensitive metric. The Fontan TO may represent a balanced measure of successful patient care.

Objective: Chest tube management after pulmonary resection is not standardized. Surgeons vary regarding the use of suction versus water seal, single versus multiple drains, drain type, and drainage threshold before removal. A randomized study was undertaken comparing standard suction (SS) of -20 cmH₂O to low suction (LS) of -8 cmH₂O using digital drainage systems. The primary aim was to demonstrate a shorter duration of air leak with LS. Secondary aims included chest tube duration, length of stay between arms, and the effectiveness of using a single 24 Fr Blake (channel) drain.

Methods: Patients scheduled for minimally invasive lung resection were eligible. The threshold for tube removal was a drainage volume of ≤450 mL/24 h and air leak of ≤20 mL/min over 6 h.

Results: A total of 148 patients were eligible (76 SS and 72 LS). There were no differences in baseline characteristics. The duration of air leak (0.9 vs 1.2 days), chest tube duration (2.1 vs 2.1 days), hospital stay (2 vs 2 days), and prolonged air leak incidence (8% vs 11%) were not significantly different. In LS patients, there were more pleural interventions required (11% vs 3%, P = 0.05) and a trend for more subcutaneous emphysema (14% vs 4%) on chest x-ray before chest tube removal.

Conclusions: The routine use of a 24 Fr Blake drain and a drainage threshold of 450 cc/24 h for chest tube removal was safe and effective. We found no advantage of LS. However, more pleural interventions were required and a trend for increased subcutaneous emphysema with LS was found, suggesting SS may be preferred when an air leak is present.