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

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.

Objective: Minimally invasive surgery for mitral annular calcification (MAC) has been reported sporadically, but data on endoscopic surgery are scarce. We summarize current surgical understanding of MAC and how it applies to endoscopic surgery through our experience.

Methods: All patients with severe MAC undergoing endoscopic mitral surgery at a single institution (December 2020 to August 2024) were studied.

Results: Twenty-five patients (3 female patients) with an average left ventricular ejection fraction of 52.12% (46.25% to 60%), average age of 69.13 (64 to 75.7) years, average body surface area of 1.92 (1.69 to 2.09) m², and average Society of Thoracic Surgeons predicted risk of mortality score of 8.30% (2.13% to 8.66%) underwent endoscopic surgery. Twelve patients had regurgitation (48%), 10 had stenosis (48%), and 3 had a combination (12%). Circumferential MAC was found in 4 patients (16%), 80% circumference in 7 (28%), 60% circumference in 7 (28%), and 40% circumference in 7 (28%). Mitral valve replacement was done in 72% (n = 18) with tissue valves (n = 11), mechanical valves (n = 4), or transcatheter balloon-expandable valves (n = 3). Seven patients (28%) had repairs. There were no operative deaths, atrioventricular complications, or strokes. The average duration of surgery was 5 h 40 min (4 h 13 min to 8 h 22 min), with average cardiopulmonary bypass and cross-clamp times of 214 (166 to 241) min and 152 (117 to 193) min, respectively. MAC was debrided in 20 patients with ultrasonic emulsification (n = 13) or mechanical debridement (n = 7).

Conclusions: Endoscopic surgery for severe MAC can be safely and successfully performed using a combination of surgical techniques including ultrasonic decalcification, mechanical debridement, annular patching, and direct implantation of balloon-expandable valves.

Objective: Open aortic repair is considered the standard of care for patients with connective tissue disease (CTD) due to the perceived durability advantages compared with endovascular intervention. However, some complex CTD patient presentations increase risk with open repair, favoring endovascular intervention. This analysis sought to review our experience with endovascular intervention in CTD patients and identify scenarios in which this approach may reasonably be considered.

Methods: Patients with CTD undergoing endovascular intervention at our institution from 2006 to 2023 were retrospectively reviewed. The primary outcome was freedom from aorta-related mortality. Secondary outcomes included all-cause mortality and freedom from secondary intervention.

Results: Forty-five CTD patients underwent endovascular intervention. Thirty-five patients (77.8%) had at least 1 previous aortic intervention. Urgent or emergent presentation was common (n = 31, 68.8%). At index hospitalization, 32 patients (71.1%) underwent thoracic endovascular aortic repair, and 6 patients (13.3%) underwent fenestrated and/or branched endovascular repair. Aneurysm (n = 40, 88.9%) and dissection (n = 36, 80.0%) were the most common indications; many patients (n = 31, 68.9%) presented with both. Freedom from aorta-related mortality was 88.7% ± 5% and 83.2% ± 6% at 1 and 3 years, respectively. No clinical or procedural factors were predictive of aorta-related mortality. Twenty-one patients (46.7%) required secondary intervention; the median time to secondary intervention was 6.5 months (6.5, 18.9 months). Freedom from secondary intervention was 60.0% ± 8% and 51.4% ± 9% at 1 and 3 years, respectively.

Conclusions: Endovascular intervention is often lifesaving in CTD patients who are not initially candidates for open repair. Aorta-related mortality was low, and fewer than half of patients required secondary intervention during the study period. This illustrates the utility of endovascular intervention in bridging CTD patients to definitive open repair.

In the evolving landscape of endoscopic aortic valve replacement (AVR), the alignment of instruments is crucial for overcoming difficulties related to the narrow aortic space. Here, we describe a technique of lateral suturing based on the principle of instrument triangulation, which allows perpendicular stiches to the aortic annulus like an open aortic valve procedure. This technique facilitates endoscopic AVR, performed through a 3 cm long right anterolateral mini-thoracotomy without rib retraction using a 3-dimensional endoscope and femoro-femoral cardiopulmonary bypass. Our approach uses a more lateral positioning of the vent and the transthoracic clamp as well as the addition of a single lateral port, which allows optimal angulation of the instruments to the aortic annulus and the ascending aorta. This technique facilitates endoscopic suturing without the use of automated devices through a transverse aortotomy. Annular sutures are placed in a perpendicular way in the aortic annulus by avoiding challenging "hook" stitches. In this case, we use an additional 10 mm port in the fourth right intercostal space through a small periareolar incision. With this technique, it is possible to implant any type of aortic prosthesis, either biological or mechanical.

Enhancing recovery protocols seek to optimize multiple aspects of care throughout the patient's perioperative cardiac surgery journey. Fast-track recovery protocols, specifically those involving earlier extubation, have been among the early methods to enhance a patient's recovery. However, how early these protocols should be implemented after surgery remains a source of ongoing controversy. Strong opinions exist on whether it is appropriate to extubate patients after cardiac surgery in the operating room (OR). Although OR extubation may offer benefits such as reduced intensive care unit length of stay and resource utilization, there are concerns regarding safety, patient selection, and inconsistent outcomes, which have raised significant controversy. This review aims to discuss the reasons why a team may consider exploring extubation in the OR and provide a practical approach for the interdisciplinary team seeking to implement this practice in appropriately selected patients.