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Becoming a congenital heart surgeon: the long and challenging road. 成为一名先天性心脏外科医生:漫长而充满挑战的道路。
4区 医学 Q2 Medicine Pub Date : 2022-10-10 DOI: 10.1093/icvts/ivac250
K A Jacob, N Hussein, A van Wijk, P P Heinisch, C Salih, L Galetti, J Hörer

Training in congenital cardiac surgery is potentially lengthier and more demanding than training in any other surgical field. The duration of training is proportional to the complexity of the specialization. The expertise of a wide range of procedures is required. There is no doubt that some individuals may acquire the requisite abilities with greater ease than others, but fundamentally, these are capabilities that can be taught and learnt. Moreover, congenital cardiac surgeons are required to have a detailed understanding of pathophysiology and morphology, in addition to the stamina and empathy required to manage these complex patients. A fellowship is just the start of such training and is followed by a long road eventually leading to a lifelong journey to become a qualified congenital cardiac surgeon. Effective mentorship is a prerequisite throughout training to guide surgeons on this journey.

先天性心脏外科的培训可能比其他任何外科领域的培训都要长,要求也更高。培训时间与专业的复杂程度成正比。需要广泛的程序方面的专门知识。毫无疑问,有些人可能比其他人更容易获得必要的能力,但从根本上说,这些能力是可以教授和学习的。此外,先天性心脏外科医生需要对病理生理学和形态学有详细的了解,以及管理这些复杂患者所需的耐力和同理心。奖学金只是这种训练的开始,之后是一条漫长的道路,最终成为一名合格的先天性心脏外科医生。有效的指导是在整个培训过程中指导外科医生的先决条件。
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引用次数: 1
Breakfast at Tiffany’s: encouraging all the best and brightest diamonds into cardiothoracic surgery 蒂凡尼的早餐:鼓励所有最好最亮的钻石都用于心胸外科手术
4区 医学 Q2 Medicine Pub Date : 2022-10-10 DOI: 10.1093/icvts/ivac249
M. Lehtinen, Maroua Eid
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引用次数: 0
Malignant pleural mesothelioma in situ. 恶性胸膜间皮瘤原位。
4区 医学 Q2 Medicine Pub Date : 2022-10-10 DOI: 10.1093/icvts/ivac255
Kohei Ando, Takao Morohoshi, Yukio Tsuura, Munetaka Masuda

Although the diagnosis of malignant pleural mesothelioma at an in situ stage was traditionally challenging, it is now possible owing to advances in molecular biological methods such as P16 fluorescence in situ hybridization or BRCA1-associated protein 1 immunohistochemistry. Here, we report the first case, to our knowledge, of total parietal pleurectomy for mesothelioma in situ. Future follow-up and accumulation of cases are necessary to determine whether total parietal pleurectomy could be applied as a treatment for mesothelioma in situ or not.

尽管恶性胸膜间皮瘤在原位阶段的诊断传统上具有挑战性,但由于分子生物学方法的进步,如P16荧光原位杂交或brca1相关蛋白1免疫组织化学,现在可以进行诊断。在这里,我们报告第一个病例,据我们所知,全胸膜壁切除原位间皮瘤。胸膜壁全切除术是否可以作为原位间皮瘤的治疗方法,需要进一步的随访和病例积累来确定。
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引用次数: 1
Augmenting mitral valve repair evaluation with intraoperative left ventricle pressure measurements. 术中测量左心室压力评价增强二尖瓣修复。
4区 医学 Q2 Medicine Pub Date : 2022-10-10 DOI: 10.1093/icvts/ivac242
Hugo Issa, Mimi Deng, Kenza Rahmouni, Vincent Chan

Surgical mitral valve repair remains the gold standard treatment of mitral regurgitation due to degenerative disease. Surgery is performed on the quiescent heart; therefore, assessments of valve repair success can only be made following separation from cardiopulmonary bypass. Intra-ventricular pressure measurements are often made in percutaneous valve procedures but has yet been described at the time of surgical repair. As an example, the saline test, whereby normal saline is injected across the mitral valve from the left atrium into the left ventricle, on the arrested heart remains an integral component of surgical repair. However, the haemodynamics of the saline test have never been evaluated. We present a simple and novel technique to quantify the saline test by passing a 22-G catheter across the mitral leaflets during saline testing under maximal ventricle distension. The saline test may be less informative among patients in whom the maximum generated left ventricle diastolic pressure is low. These data may be of help to a surgeon interpreting intraoperative saline tests with the hope of a competent mitral valve. As well, it may provide support for intraventricular pressure monitoring at the time of mitral valve surgery.

手术二尖瓣修复仍然是治疗退行性疾病引起的二尖瓣反流的金标准。手术在静止的心脏上进行;因此,对瓣膜修复成功的评估只能在体外循环分离后进行。心室内压力测量通常在经皮瓣膜手术中进行,但尚未在手术修复时进行描述。例如,生理盐水试验,将生理盐水从左心房穿过二尖瓣注入左心室,在停跳的心脏上,仍然是手术修复的一个组成部分。然而,生理盐水试验的血流动力学从未被评估过。我们提出了一种简单而新颖的方法,通过在最大心室扩张的生理盐水测试中通过22g导管穿过二尖瓣小叶来量化生理盐水测试。生理盐水试验在左心室最大舒张压较低的患者中可能信息较少。这些数据可能有助于外科医生解释术中生理盐水试验,以期获得合格的二尖瓣。同时,它也可以为二尖瓣手术时的脑室内压力监测提供支持。
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引用次数: 1
Acute Kidney Injury after High-Flow Regional Cerebral Perfusion in Neonatal and Infant Aortic Arch Repair. 新生儿和婴儿主动脉弓修复术中高流量区域脑灌注后的急性肾损伤。
4区 医学 Q2 Medicine Pub Date : 2022-09-19 DOI: 10.1093/icvts/ivac247
Fumiaki Shikata, Kagami Miyaji, Satoshi Kohira, Hiroshi Goto, Torii Shinzo, Tadashi Kitamura, Toshiaki Mishima, Masaomi Fukuzumi, Shunichiro Fujioka, Akihiro Sasahara, Haruna Araki

Objectives: We applied high-flow regional cerebral perfusion (HFRCP) for aortic arch reconstruction in neonates and infants by monitoring regional oxygen saturation of the thigh (rSO2T) using near-infrared spectroscopy to maintain peripheral perfusion. This study was designed to investigate the optimal perfusion flow of HFRCP for renal protection.

Methods: From 2009 to 2021, 28 consecutive neonates and infants who underwent aortic arch reconstruction with HFRCP were enrolled. The median age of the patients was 27 days; the median body weight was 3.0 kg. In HFRCP, perfusion flow was targeted at approximately 80-100 mL/kg/min and then lowered corresponding to brain rSO2 levels and blood gas data. Isosorbide dinitrate and chlorpromazine were administered to enhance peripheral perfusion flow. Regional oxygen saturation of the forehead and thighs were monitored. The stage of acute kidney injury (AKI) was classified based on the Kidney Disease Improving Global Outcomes criteria.

Results: No patients had neurological events and peritoneal dialysis after surgery. The incidence of AKI was 39.3% with only three patients having greater than stage 2 AKI. The maximum postoperative serum creatinine concentration was negatively associated with the lowest rSO2T during HFRCP. The rSO2T during HFRCP was a predictive factor for postoperative creatinine increase of ≧0.3 mg/dL. The area under receiver operating characteristic curve was 0.78 with the cutoff value of 48% for rSO2T.

Conclusions: The rSO2T during HFRCP is a potential predictor of postoperative renal function. To prevent AKI, the rSO2T should be preserved more than 48% by increasing HFRCP flow.

目的:我们将高流量区域脑灌注(HFRCP)应用于新生儿和婴儿的主动脉弓重建,通过使用近红外光谱监测大腿区域血氧饱和度(rSO2T)来维持外周灌注。本研究旨在探讨 HFRCP 保护肾脏的最佳灌注流量:方法:从 2009 年到 2021 年,连续 28 名新生儿和婴儿接受了 HFRCP 主动脉弓重建术。患者的中位年龄为 27 天,中位体重为 3.0 千克。在 HFRCP 中,灌注流量的目标值约为 80-100 mL/kg/min,然后根据脑部 rSO2 水平和血气数据降低灌注流量。使用二硝酸异山梨酯和氯丙嗪来增强外周灌注流量。对前额和大腿的区域血氧饱和度进行了监测。急性肾损伤(AKI)的分期是根据肾病改善全球结果标准划分的:结果:术后没有患者发生神经系统事件和腹膜透析。AKI发生率为39.3%,只有3名患者的AKI超过2期。术后最高血清肌酐浓度与 HFRCP 期间的最低 rSO2T 呈负相关。HFRCP 期间的 rSO2T 是术后肌酐升高≧0.3 mg/dL 的预测因素。rSO2T的临界值为48%时,接收者操作特征曲线下面积为0.78:结论:HFRCP期间的rSO2T是术后肾功能的潜在预测指标。为预防 AKI,应通过增加 HFRCP 流量将 rSO2T 保持在 48% 以上。
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引用次数: 0
Is mood associated with perception of recovery? Preoperative depression versus postoperative delirium after cardiac surgery. 情绪是否与恢复知觉有关?心脏手术后术前抑郁与术后谵妄。
4区 医学 Q2 Medicine Pub Date : 2022-09-09 DOI: 10.1093/icvts/ivac229
Ari A Mennander

The author alone is responsible for the Invited Commentary, which does not necessarily reflect the policy of the Journal.

作者独自负责特邀评论,这并不一定反映本刊的政策。
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引用次数: 0
Feasibility and long-term outcomes of surgery for primary thoracic synovial sarcoma. 原发性胸滑膜肉瘤手术治疗的可行性及远期疗效。
4区 医学 Q2 Medicine Pub Date : 2022-09-09 DOI: 10.1093/icvts/ivac238
Sara Pieropan, Olaf Mercier, Delphine Mitilian, Pauline Pradère, Dominique Fabre, Daniela Iolanda Ion, Olivier Mir, Barbara Galbardi, Vincent Thomas De Montpreville, Elie Fadel

Objectives: Primary thoracic synovial sarcoma (SS) is a rare, high-grade, malignancy. Involvement of vital organs is frequent and may decrease the benefits of surgical resection. We reviewed our practice at a highly experienced thoracic-surgery centre to assess early- and long-term outcomes after surgery.

Methods: We conducted a retrospective, observational, single-centre study of patients undergoing curative-intent surgery for primary thoracic SS between 1 January 2000 and 31 January 2021 as part of a multidisciplinary management. We assessed demographics, medical history, histopathology and follow-up information.

Results: We enrolled 20 patients (13 males) with a median age of 40 years old and a median tumour size of 11 cm. Neoadjuvant chemotherapy was administered to 13 patients. Surgery consisted in extrapleural pneumonectomy (n = 7), extrapleural lobectomy (n = 5), chest wall resection (n = 4) or tumour resection (n = 4). R0 resection was achieved in 16 (80%) patients. Adjuvant therapy was given to 13 patients. 6 patients developed postoperative complications. The median hospital stay was 11.5 days. Overall survival at 2 and 5 years was 51% and 22%, respectively; median overall survival was 25 months and median disease-free survival was 8.5 months. Relapses occurred in 15 patients. By univariate analysis, incomplete resection was the only significant predictor of survival (P = 0.01).

Conclusions: Primary thoracic SS is an aggressive disease. Surgery included in a multimodal treatment may contribute to achieving a good outcome, providing that an R0 resection is obtained. Given the considerable technical challenges of surgery, patient selection and referral to an experienced centre are crucial to minimize morbidity and mortality.

目的:原发性胸椎滑膜肉瘤(SS)是一种罕见的高级别恶性肿瘤。经常累及重要器官,可能降低手术切除的益处。我们回顾了我们在一家经验丰富的胸外科中心的实践,以评估手术后的早期和长期结果。方法:我们对2000年1月1日至2021年1月31日期间接受旨在治愈的原发性胸椎SS手术的患者进行了一项回顾性、观察性、单中心研究,作为多学科管理的一部分。我们评估了人口统计学、病史、组织病理学和随访信息。结果:我们招募了20例患者(13例男性),中位年龄为40岁,中位肿瘤大小为11厘米。13例患者接受新辅助化疗。手术包括胸膜外全肺切除术(n = 7)、胸膜外肺叶切除术(n = 5)、胸壁切除术(n = 4)或肿瘤切除术(n = 4)。16例(80%)患者实现R0切除。辅助治疗13例。6例出现术后并发症。平均住院时间为11.5天。2年和5年的总生存率分别为51%和22%;中位总生存期为25个月,中位无病生存期为8.5个月。15例患者复发。单因素分析显示,不完全切除是唯一显著的生存预测因子(P = 0.01)。结论:原发性胸椎SS是一种侵袭性疾病。如果获得R0切除,包括在多模式治疗中的手术可能有助于获得良好的结果。鉴于外科手术的相当大的技术挑战,患者的选择和转诊到有经验的中心是至关重要的,以尽量减少发病率和死亡率。
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引用次数: 0
Preoperative P-wave parameters and risk of atrial fibrillation after cardiac surgery: a meta-analysis of 20 201 patients. 心脏手术后术前p波参数与房颤风险:20201例患者的荟萃分析
4区 医学 Q2 Medicine Pub Date : 2022-09-09 DOI: 10.1093/icvts/ivac220
Michal J Kawczynski, Sophie Van De Walle, Bart Maesen, Aaron Isaacs, Stef Zeemering, Ben Hermans, Kevin Vernooy, Jos G Maessen, Ulrich Schotten, Elham Bidar

Objectives: To evaluate the role of P-wave parameters, as defined on preprocedural electrocardiography (ECG), in predicting atrial fibrillation after cardiac surgery [postoperative atrial fibrillation (POAF)].

Methods: PubMed, Cochrane library and Embase were searched for studies reporting on P-wave parameters and risk of POAF. Meta-analysis of P-wave parameters reported by at least 5 different publications was performed. In case of receiver operator characteristics (ROC-curve) analysis in the original publications, an ROC meta-analysis was performed to summarize the sensitivity and specificity.

Results: Thirty-two publications, with a total of 20 201 patients, contributed to the meta-analysis. Increased P-wave duration, measured on conventional 12-lead ECG (22 studies, Cohen's d = 0.4, 95% confidence interval: 0.3-0.5, P < 0.0001) and signal-averaged ECG (12 studies, Cohen's d = 0.8, 95% confidence interval: 0.5-1.2, P < 0.0001), was a predictor of POAF independently from left atrial size. ROC meta-analysis for signal-averaged ECG P-wave duration showed an overall sensitivity of 72% (95% confidence interval: 65-78%) and specificity of 68% (95% confidence interval: 58-77%). Summary ROC curve had a moderate discriminative power with an area under the curve of 0.76. There was substantial heterogeneity in the meta-analyses for P-wave dispersion and PR-interval.

Conclusions: This meta-analysis shows that increased P-wave duration, measured on conventional 12-lead ECG and signal-averaged ECG, predicted POAF in patients undergoing cardiac surgery.

目的:评价术前心电图(ECG)定义的p波参数在预测心脏手术后心房颤动(POAF)中的作用。方法:检索PubMed、Cochrane文库和Embase中关于p波参数与POAF风险的研究。对至少5份不同出版物报道的p波参数进行meta分析。对于原始出版物中的接受者操作者特征(ROC曲线)分析,进行ROC荟萃分析以总结敏感性和特异性。结果:32篇出版物,共20201例患者参与了meta分析。常规12导联心电图测量的P波持续时间增加(22项研究,Cohen’s d = 0.4, 95%可信区间:0.3-0.5,P)结论:本荟萃分析显示,常规12导联心电图和信号平均心电图测量的P波持续时间增加可预测心脏手术患者的POAF。
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引用次数: 0
Low copper levels measured in the aortic wall of New Zealand patients with non-syndromic ascending thoracic aortic aneurysm. 新西兰无综合征性胸升主动脉瘤患者主动脉壁铜含量低。
4区 医学 Q2 Medicine Pub Date : 2022-09-09 DOI: 10.1093/icvts/ivac235
Adam El-Gamel, Josephenine Mak, Steve Bird, Megan N C Grainger, Gregory M Jacobson

Objectives: Studies in animals have shown causal relationships between copper (Cu) deficiency and the development of thoracic aortic aneurysms (TAAs) [1, 2]. Cu deficiency is widespread in New Zealand (NZ) soils; the high soil pH from the use of lime fertilizers reduces the bioavailability of Cu for grazing animals and growing plants; this, in turn, reduces Cu availability in the NZ human food chain. Our study is a pilot study to explore associations between Cu and TAA. We measured Cu levels in aneurysmal aortic tissues in patients undergoing Bentall procedures and non-aneurysmal aortic tissue from coronary artery bypass graft patients.

Methods: Aortic samples were collected from 2 groups of patients during elective open-heart surgery over 4 months between November 2017 and February 2018. The groups were a TAA group, patients with non-syndromic aortic aneurysm and without the bicuspid aortic valve or known infectious or inflammatory condition (ANEURYSM; n = 13), and a control coronary artery bypass graft group (CONTROL; n = 44). Standardized digested dry tissue weighed samples were analysed from both groups. Tissue extraction of trace elements was carried out using HCl-H2O2 digestion and a highly sensitive analytical technique, inductively coupled plasma mass spectrometry-used to measure elemental concentrations.

Results: Cu concentration (mean ± SD) was significantly lower in ANEURYSM (3.34 ± 0.16 µg/g) when compared to the CONTROL group tissues (4.33 ± 0.20 µg/g) (dry weight; mean ± SD; Student's t-test, P < 0.05). Over 46% of the Aneurysm patients were Maori and live in a geographically Cu-deficient NZ territory.

Conclusions: Cu deficiency may play a role in the development or progression of non-syndromic ascending aortic aneurysms in NZ. Maori patients are more at risk as they commonly live in rural NZ, dependent on locally grown nutritional sources. Further studies are required to confirm this exciting finding and to establish cause and effect relationship.

目的:动物研究表明铜(Cu)缺乏与胸主动脉瘤(TAAs)的发展之间存在因果关系[1,2]。铜缺乏在新西兰(NZ)土壤中很普遍;石灰肥料的使用导致土壤pH值升高,降低了放牧动物和生长植物对铜的生物利用度;这反过来又减少了新西兰人类食物链中铜的可用性。我们的研究是一项探索Cu和TAA之间关系的初步研究。我们测量了本特尔手术患者的动脉瘤性主动脉组织和冠状动脉搭桥术患者的非动脉瘤性主动脉组织中的铜水平。方法:选取2017年11月至2018年2月期间进行择期心内直视手术的两组患者的主动脉标本,时间跨度超过4个月。两组分别为TAA组、无综合征性主动脉瘤、无二尖瓣主动脉瓣或已知感染性或炎症性疾病(动脉瘤;n = 13),另设冠状动脉旁路移植术对照组(control;n = 44)。对两组标准化消化干组织称重样本进行分析。组织中微量元素的提取采用HCl-H2O2消解法和高灵敏度分析技术电感耦合等离子体质谱法测定元素浓度。结果:动脉瘤组Cu浓度(平均±SD)(3.34±0.16µg/g)明显低于对照组(4.33±0.20µg/g)(干重;平均值±SD;结论:铜缺乏可能在新西兰非综合征性升主动脉瘤的发生或发展中起作用。毛利人患者的风险更大,因为他们通常生活在新西兰农村,依赖当地种植的营养来源。需要进一步的研究来证实这一令人兴奋的发现,并建立因果关系。
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引用次数: 0
Drainless thoracoscopic surgery should be avoided in primary spontaneous pneumothorax with pleural adhesion. 原发性自发性气胸合并胸膜粘连应避免无引流胸腔镜手术。
4区 医学 Q2 Medicine Pub Date : 2022-09-09 DOI: 10.1093/icvts/ivac237
Chieh-Kuo Lin, Ka-I Leong, Cheng-Hung How, Hu-Lin Christina Wang, Chao-Yu Liu

Objectives: Drainless thoracoscopic surgery, defined by omitting chest drain after surgery, has been demonstrated to be feasible in selected patients for pulmonary resection. However, drainless procedure for the treatment of primary spontaneous pneumothorax has raised concerns for its safety and thus has been less often reported. We aimed to share our preliminary experience regarding how to select patients with spontaneous pneumothorax for this procedure.

Methods: A retrospective study recruiting 303 consecutive patients with the diagnosis of spontaneous pneumothorax undergoing thoracoscopic surgery in our centre from August 2016 to June 2020 was done. After careful selection, the chest drain was omitted in selected patients who underwent non-intubated uniportal thoracoscopic surgery. Patients' clinical characteristics and perioperative outcomes were analysed.

Results: A total of 34 patients underwent drainless thoracoscopic surgery for the treatment of spontaneous pneumothorax. Pleural adhesion was noted in 9 patients during surgery, and all of them (100%) developed residual pneumothorax, among which intercostal drainage was required in 2 (22.2%) patients and ipsilateral pneumothorax recurred 3 years after surgery in 1 (11.1%) patient. Among the remaining 25 without pleural adhesion, 17 (68.0%) developed minor residual pneumothorax (P = 0.006), which all resolved spontaneously within 1-2 weeks, with no complications or recurrence during postoperative follow-up for at least 2 years.

Conclusions: Drainless thoracoscopic surgery for the treatment of primary spontaneous pneumothorax is feasible but can be risky without careful patient selection. In our experience, the drainless procedure should be avoided in patients with identifiable pleural adhesion noted during surgery.

目的:无引流胸腔镜手术的定义是术后不引流胸腔,已被证明在特定的肺切除术患者中是可行的。然而,无引流术治疗原发性自发性气胸引起了人们对其安全性的担忧,因此报道较少。我们的目的是分享我们关于如何选择自发性气胸患者进行该手术的初步经验。方法:回顾性研究2016年8月至2020年6月在我中心连续招募303例经胸腔镜手术诊断为自发性气胸的患者。经慎重选择,选择行非插管单门胸腔镜手术的患者,省略胸腔引流。分析患者的临床特点及围手术期结果。结果:34例患者行无引流胸腔镜手术治疗自发性气胸。9例患者术中出现胸膜粘连,全部(100%)发生残留气胸,其中2例(22.2%)患者需要肋间引流,1例(11.1%)患者术后3年复发同侧气胸。其余25例无胸膜粘连患者中,17例(68.0%)出现轻度残余气胸(P = 0.006),均在1 ~ 2周内自行消退,术后随访至少2年无并发症或复发。结论:无引流胸腔镜手术治疗原发性自发性气胸是可行的,但如果不仔细选择患者可能存在风险。根据我们的经验,在手术中发现明显胸膜粘连的患者应避免采用无引流术。
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引用次数: 1
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Interactive cardiovascular and thoracic surgery
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