Journal of Cardiac Surgery最新文献

Background: Traditional risk scoring tools have assisted to guide surgical practice for decades. Machine learning algorithms build upon this concept to allow dynamic and tailored patient information. These algorithms have been employed across most surgical specialties with multiple aims, including cost of care assessment, risk stratification, and prediction of procedural survival.

Methods: Paper selection was based on three main criteria: relevance, recency, and novelty. Relevant studies were identified through a comprehensive search of major databases, including PubMed and Scopus.

Results: Machine learning algorithms pose significant advantages compared to traditional risk scoring tools. Across cardiac and noncardiac specialties, multiple studies have identified machine learning algorithms as superior to control or traditional scoring tools at diagnosis.

Conclusion: In this focused analysis, we have identified the potential of machine learning to aid in diagnosis, management, and prediction of postoperative outcomes. Surgeons must continue to integrate machine learning into their practice with the aim of improving both patient and surgeon-based outcomes.

Objectives: We aimed to investigate whether the no-touch (NT) harvesting technique for the great saphenous vein graft (SVG) affects graft flow velocity during coronary artery bypass grafting.

Methods: The study included 132 and 138 conduits that underwent NT and conventional (CV) harvesting techniques, respectively (NT and CV groups, respectively). Transit-time flow measurements and contrast-enhanced computed tomography (CT) were performed to assess graft flow velocity and patency.

Results: Intraoperative graft flows, assessed using a transit-time flowmeter, were 40 ± 19 and 48 ± 27 mL/min/anastomosis in the NT and CV groups, respectively. Preoperative SVG diameters, assessed via vascular ultrasound, were 2.8 ± 0.7 and 2.8 ± 0.8 mm in the NT and CV groups, respectively. However, postoperative SVG diameters, measured using contrast-enhanced CT, were 2.7 ± 0.5 and 3.5 ± 0.6 mm in the NT and CV groups, respectively, indicating a significant reduction in the NT group (p < 0.01). Graft flow velocities, calculated from graft flow and vascular diameter, were 7.3 ± 4.2 and 5.4 ± 3.2 cm/s/anastomosis in the NT and CV groups, respectively, being significantly higher in the NT group (p < 0.01). The incidence of postoperative occlusion was significantly lower in the NT group (two conduits, 1.5%) than in the CV group (10 conduits, 7.3%) (p = 0.02). Significant differences were found in the 5-year patency rates between the two groups (NT group, 98.4%; CV group, 92.9%; p = 0.04).

Conclusions: The NT SVG harvesting technique prevents postoperative graft diameter expansion and significantly increases graft flow velocity and patency. Further randomized studies are needed to determine whether differences in blood flow velocity are essential for graft patency over an extended observation period.

Background: Measuring living heart anatomy using three-dimensional (3D) images remains challenging. To address this, a method called isosurface measurement on volume-rendered images (IMVR) has been developed. This study aims to validate IMVR in quantitative measurement by comparing it with curved planar reformation (CPR).

Methods: Five 3D-printed human cardiac models created from computed tomography (CT) images were optically scanned, and selected features were measured for reference. The models were CT-scanned, and the datasets were processed for IMVR and CPR measurements. Overall, 157 anatomical features (105 in the aortic root, 52 in the coronary artery) were measured three times by two observers for each method, and the agreement with the reference values was assessed using the Bland–Altman analysis.

Results: In the aortic root measurement, the lower and upper 95% limits of agreement (LOAs, mm) for IMVR were (−3.1, 2.4) and (−1.3, 0.9), whereas those for CPR were (−5.9, 5.2) and (−5.9, 6.3). In the coronary artery measurement, the LOAs for IMVR were (−2.6, 2.2) and (−1.2, 0.8), while those for CPR were (−9.2, 8.6) and (−9.5, 8.5). For both methods, the intraclass coefficient indicated high intra- and interobserver reliability.

Conclusion: IMVR demonstrated greater precision than CPR and facilitated 3D measurements of complex cardiovascular features.

Patients with end-stage renal disease (ESRD) and concomitant coronary artery disease (CAD) present unique challenges for coronary revascularization. While coronary artery bypass grafting (CABG) is recommended over percutaneous coronary intervention in this population, the optimal surgical strategy remains controversial. This meta-analysis provides an updated comparison of outcomes for ESRD patients undergoing CABG with either bilateral internal thoracic artery (BITA) or single internal thoracic artery (SITA) grafting. A total of nine studies involving 911 patients were included. Our findings revealed no significant differences in perioperative mortality (p = 0.57), deep sternal wound infection (p = 0.41), or major adverse cardiac and cerebrovascular events (p = 0.54) between groups. Long-term survival rates were also comparable at one, three, five, and seven years postoperatively. The pooled hazard ratio for all-cause mortality was 0.82 (95% CI: 0.61–1.12; p = 0.21), indicating no explicit survival advantage for either grafting strategy. These results are consistent with existing literature and suggest that both BITA and SITA grafting are safe and effective in this high-risk group. As medical advances continue to extend the life expectancy of patients with ESRD, additional research focused on optimizing the management of ESRD-related CAD will be essential to improving perioperative and long-term outcomes for these high-risk patients.

Introduction and Objectives: Infective endocarditis (IE) presents a high mortality rate despite medical and surgical advances. The objective of this study is to describe our experience in the surgical treatment of left-sided valvular IE.

Methods: A retrospective analysis was performed on patients operated for left-sided valvular IE from March 2006 to August 2023. Fine-gray competitive risk regression model was used to analyze recurrence, while logistic regression and Cox regression models were assessed to identify independent variables associated with hospital mortality and long-term mortality.

Results: Out of 566 patients diagnosed with IE, 352 (62.2%) underwent surgery for left-sided valvular involvement. Of these patients, 65.9% were male with a median age of 67.8 years. The causative microorganism was isolated in 84.4% of cases. Hospital mortality was 19.0% (n = 67). Age over 69 years and preoperative cardiogenic shock were independent risk factors for hospital mortality. A recurrence of endocarditis was observed in 11.7% (n = 41) of patients (26 relapses and 15 reinfections), with prosthetic endocarditis being an independent risk predictor (HR 2.03 (CI 1.09–3.79); p = 0.004). Survival rates at 1, 5, and 10 years were 75.2%, 66.2%, and 47.1%, respectively. Age over 60 years, preoperative cardiogenic shock, preoperative moderate left ventricular dysfunction, mitral surgery, postoperative low cardiac output, postoperative acute kidney injury AKIN III, and postoperative stroke were independent variables associated with long-term mortality.

Conclusions: Surgery is indicated in more than 60% of patients with IE. Despite this, IE remains a complex disease associated with high in-hospital morbidity and mortality and a decrease in long-term survival.

Background: Prolonged intensive care unit (ICU) length of stay (LOS) following cardiac surgery has been associated with higher resource utilization and increased in-hospital mortality. Few reports have investigated the association between prolonged ICU LOS and subsequent mortality following hospital discharge.

Methods: The relationship between ICU LOS and 1-year all-cause mortality was assessed in 2799 patients treated with coronary artery bypass grafting with and without concomitant valve surgery at a large tertiary center between January 1, 2017, and December 31, 2021. Multivariable logistic regression and Cox proportional hazards regression examined ICU LOS as a predictor of 1-year mortality and to define the risk of mortality for ICU stays ranging from < 4 to > 14 days.

Results: Patients (N = 2799) included 76.1% males and 23.9% females aged 67.9 ± 9.9 years. Surgeries included isolated CABG (76.9%) and CABG with valve surgery (23.1%). Patients had a median ICU LOS of 1.93 days (IQR = 2.71), and 92 patients (3.3%) expired within 1 year of hospital discharge. ICU LOS was a significant predictor of 1-year mortality (OR = 1.09, 95% CI = 1.06, 1.12, p < 0.001), while controlling for significant covariates. The prevalence of 1-year all-cause mortality progressively increased by ICU LOS cutoffs: < 4 days (1.9%), ≥ 4 days (7.2%), > 7 days (17.5%), and > 14 days (31.9%). Survival analysis further indicated that 1-year mortality risk increased by ICU LOS cutoffs: ≥ 4 days (HR = 1.88, 95% CI = 1.19, 2.98, p = 0.007), > 7 days (HR = 3.80, 95% CI = 2.31, 6.25, p < 0.001), and > 14 days (HR = 10.15, 95% CI = 5.64, 18.25, p < 0.001).

Conclusions: For each additional ICU day following CABG with and without valve surgery, the odds of 1-year mortality increased by 9.0% when controlling for significant covariates. The risk of 1-year all-cause mortality increased by 88%, 280%, and 915% for ICU LOS ≥ 4 days, > 7 days, and > 14 days, respectively. These data indicate the need for more frequent postdischarge medical surveillance in patients with prolonged ICU stay.

Background: Surgical dogma advocates for the use of homograft in invasive aortic valve endocarditis due to a perceived advantage in the prevention of recurrent infection. However, conclusive data to support this strategy are lacking. This study evaluated outcomes of root replacement in invasive aortic valve endocarditis using homografts or prosthetic-valved conduits.

Methods: A retrospective review of a single U.S. academic center’s aortic database identified 150 patients who underwent aortic root replacement for invasive aortic valve endocarditis from 2002 to 2022. Patients undergoing the Ross procedure or aortic valve replacement without root replacement were excluded from the study. Patients were divided into two groups based upon the type of valved conduit implanted. Preoperative characteristics, postoperative morbidity, reintervention for recurrence of infection, and short- and long-term survival were compared between the two groups.

Results: There were 70 patients who underwent a homograft root replacement (homograft), and 80 patients who received either a bioprosthetic or mechanical-valved conduit (prosthetic). The mean age of patients was 53.3 ± 15.6 and 21.3% were female. The overall incidence of preoperative stroke and aortic root abscess was 42% and 71%, respectively. There was no difference between the two groups in age, gender, end-stage renal disease, cardiogenic shock, and aortic root abscess. The prosthetic group had a higher incidence of preoperative stroke (prosthetic 52% vs. homograft 25%, p = 0.02). The incidence of preoperative prosthetic valve endocarditis was 30% for the cohort and significantly higher in the homograft group (p = 0.02). Reoperative sternotomy was 78.7% among the groups with a higher likelihood among the homograft group. Cardiopulmonary bypass and cross clamp times were shorter in the prosthetic group (p < 0.05). There was no difference in postoperative stroke or renal failure between the two groups. The 30-day mortality for the entire cohort was 20.1% and was increased in the homograft group (homograft 25.7% vs. prosthetic 16.3%, p = 0.15). At 7 years follow-up, survival was 62% in the prosthetic group and 53% in the homograft group. The need for reintervention due to recurrence of infection was 3.2% for the entire series and equivalent (homograft 3.5%, vs. prosthetic 4.2%, p = 0.82) between the groups.

Conclusions: The use of homograft for root replacement does not provide significant improved short- or long-term outcomes compared with prosthetic-valved conduits in invasive endocarditis. In this patient population, these data refute the necessity for a more complex procedure using homograft in these high-risk patients and conduit selection should be tailored to individual anatomy and surgeon-specific experience.

Background: With the increasing adoption of robotic technology in adult cardiac surgery patients, improved surgeon experience and wider utilization have been reported. However, interpreting trends in robotic congenital surgery is more challenging. By performing a systematic review, the authors aim to evaluate the current literature on robotic congenital operations.

Methods: The protocol was registered with PROSPERO. The inclusion and exclusion criteria were established based on the population, intervention, comparison, and outcome (PICO) framework. A comprehensive literature search was conducted from January 1998 to December 2021. Studies involving patients undergoing congenital cardiac surgery operations performed with robotic assistance were included. Two independent reviewers screened titles/abstracts and then full text of eligible studies. A third reviewer resolved any discrepancies. The Newcastle–Ottawa Scale was applied to quantify quality assessment for nonrandomized observational studies.

Results: A total of one-hundred twenty-eight publications underwent full-text review, and 66 studies were included. Overwhelmingly, the majority are from single institutions and observational and retrospective studies. The population was mostly adults with only 10.6% (7/66) studies solely reporting pediatric patients. About 50% of the studies were case reports (28/66). Selective reporting of outcomes varied widely across studies. Cumulative mortality rates were 0.3%. The highest incidence of morbidities included pleural effusion (12.3%), reoperation for bleeding (10.7%), atrial fibrillation (10.7%), heart block (9.5%), and peripheral cannulation–related complications (8.6%). The overall quality of the studies was unsatisfactory, with the majority of studies receiving a score of 3 out of 9.

Conclusions: Most publications were case reports or small case series performed in adults and restricted to a few international institutions. To address these clinical challenges, technological improvements and advanced training will be mandatory before wider application to children and complex congenital diagnoses. Unfortunately, the overall quality of studies is poor, with inconsistent outcomes reporting. Improved and standardized reporting will be necessary before an appropriate evaluation of robotics in the treatment of congenital heart disease is feasible.

Background: Mitral valve repair with the edge-to-edge technique (Alfieri stitch) has been described for over 20 years, yet little is published on late durability and potential risk of mitral stenosis remains controversial. The primary objective of this study is to describe characteristics and late durability of Alfieri stitch in mitral valve repair.

Methods: From 2004 to 2019, we reviewed data from our prospectively maintained institutional database on 1175 consecutive patients with degenerative mitral regurgitation (MR) who underwent repair. Patients undergoing concomitant operations were included. Propensity score matching was performed on patients with and without Alfieri stitch to compare clinical (survival and reoperation) and echocardiographic (moderate or severe MR [“moderate or more MR”], severe MR, and mitral stenosis) outcomes up to 10 years.

Results: Overall, 1175 patients underwent mitral valve repair; 55.1% (n = 648) received the Alfieri stitch. The median follow-up was 4.7 (2.0, 8.2) years. Matched patients with and without Alfieri stitch had similar cumulative incidence (CI) of moderate or more MR (24% ± 5% vs. 17% ± 4%, p = 0.2, respectively), severe MR (5% ± 2% vs. 4% ± 2%, p = 0.3), and mitral reoperation (9% ± 3% vs. 2% ± 1%, p = 0.06) with no difference in survival (84% ± 3% vs. 81% ± 3%, p = 0.2). The Alfieri stitch resulted in a slightly higher mean mitral valve gradient (3.9% ± 1.5 mmHg vs. 3.6% ± 1.6 mmHg, p = 0.0003). The CI of mitral stenosis at 10 years was negligible (one patient with Alfieri stitch and two patients without Alfieri stitch).

Conclusions: In selected patients with degenerative mitral regurgitation, mitral valve repair with Alfieri stitch is durable with late outcomes comparable with other repair techniques. The Alfieri stitch may be a useful tool in selecting complex mitral pathology with minimal increased incidence of mitral stenosis. Further investigation is needed to delineate best indications for the use of Alfieri stitch.