Journal of thoracic disease最新文献

Background: The clinical characteristics and predictors for aortic adverse events (AAEs) after thoracic endovascular aortic repair (TEVAR) of non-hypertensive aortic dissection (AD) patients remain unclear. This study sought to clarify the clinical features of non-hypertensive AD and its incidence of AAEs after TEVAR.

Methods: Clinical data were collected from the electronic medical records, imaging databases and follow-up. Baseline characteristics were balanced by propensity score matching (PSM). Kaplan-Meier analysis and Cox proportional hazards regression analysis were performed to asses postoperative AAEs and risk factors.

Results: Eight hundred and eighty-eight eligible AD patients who had received TEVAR were included. The proportion of males (72.2% vs. 80.6%, P=0.006) and the mean age of onset (55.17±14.95 vs. 59.08±13.34 years, P=0.001) were lower in the non-hypertension group. Type A dissection still accounted for a higher proportion in the non-hypertensive group than the hypertensive group (38.2% vs. 28.3%, P=0.02) after matching. Non-hypertensive AD showed a lower mean survive time (36.65±2.08 vs. 42.74±1.41 months, P=0.01) with a higher 5-year adverse event ratio (37.4% vs. 29.0%, P=0.05). Hazard ratio (HR) of type A dissection, international normalized ratio (INR), prothrombin time (PT), aortic root diameter (AoRoot) and left ventricular volume associated with AAEs after TEVAR were 3.348 [95% confidence interval (CI): 2.313-4.846], 269.197 (95% CI: 3.46-20,946.462), 0.595 (95% CI: 0.369-0.959), 2.446 (95% CI: 1.542-3.880), 1.008 (95% CI: 1.004-1.012), respectively.

Conclusions: Non-hypertensive patients presented a higher proportion of female and type A classification, and a younger mean age of TEVAR treatment. Preoperative indicators including Stanford classification, PT, activated partial thromboplastin time (APTT), AoRoot and left ventricular volume were major risk factors for adverse events after TEVAR, which deserve to be further explored and evaluated for its predictive value for better management of AD.

Background: In the process of video-assisted thoracoscopic surgery (VATS) for lung nodule resection, lung is leaded to atelectasis. However, preoperative computed tomography (CT) images are taken during inspiration, which means they differ significantly from the lung status observed during surgery. Consequently, this discrepancy can make the localization of small or subsolid nodules challenging during the operation. This study aimed to develop a CT-based virtual atelectasis simulation system for noninvasive lung nodule localization. By accurately simulating atelectasis, this study aimed to improve the precision of presurgical planning from lung nodule resections.

Methods: This study retrospectively examined 20 patients who had either subsolid nodules or small nodules less than 3 cm in size, selected from a cohort of 279 patients who underwent VATS surgery for lung nodules in Korea University Ansan Hospital between June 28, 2021, and January 22, 2024. Chest CT images of the lungs of 20 patients were acquired, and image data were converted three-dimensional models. The mesh points extracted from these lung models were manipulated to simulate the effects of gravity, by adjusting the lung shapes and nodule locations to align with the respective surgical postures of the patients. Subsequently, we assessed the similarity of the simulation by comparing the resulting deformed lung shapes and nodule locations with the corresponding perspectives observed in the surgical videos.

Results: The average volume of the entire lung among the patients was 2,336 cm³ (±588). After atelectasis simulation, the average lung shrinkage rate was 48.6% (±12.9%). Evaluations of an average of 15 pairs of images per case revealed significant conformity between atelectasis simulation images and surgical video snapshots, with average Dice and Jaccard similarity coefficient values of 90.27 and 88.25, respectively. Furthermore, the alignment of nodule locations between the simulations and surgical anticipation demonstrated notable accuracy, with an average Hausdorff distance of 6.39 mm.

Conclusions: We successfully developed a simulation of lung atelectasis based on preoperative CT scans that closely resembled actual surgical videos. The integration of this presurgical atelectasis simulation is anticipated to enhance the accuracy of nodule locations, thus contributing to more efficient and precise surgical planning.

Acute pulmonary embolism (APE) has a high mortality rate worldwide. The cause of death from pulmonary embolism (PE) is predominantly progressive right heart failure, which is common in intermediate-high-risk and high-risk patients. The latest guidelines recommend reperfusion thrombolytic therapy for high-risk patients, but it is rarely practiced clinically, given the high rate of intracranial hemorrhage. Moreover, the optimal treatment for intermediate-risk patients remains undetermined. With the development of technology, a series of endovascular interventional treatments are widely used in patients with intermediate-high-risk or high-risk PE, such as standard catheter-directed thrombolysis (SCDT), ultrasound-assisted thrombolysis (USAT), pharmacomechanical catheter-directed thrombolysis (PM-CDT) and mechanical thrombectomy (MT). Current studies have shown that interventional therapy can effectively improve right heart function and reduce the incidence of cerebral hemorrhage. Future research should mainly focus on screening patients who benefit from interventional therapy, reducing mortality, and improving long-term sequelae. This article aimed to review these treatment devices and provide an update on the research progress related to interventional therapy for PE. In addition, we introduce a risk stratification assessment for APE in the updated guidelines and provide an overview of risk indicators and APE scores for judging prognosis. Finally, we discuss the long-term outcomes of APE in combination with interventional therapy.

Background: High spinal anesthesia (HSA) has been utilized in cardiac surgery; however, there is limited evidence on its impact on facilitating postoperative recovery. This study aimed to evaluate the impact of HSA in pediatric congenital heart surgery on postoperative recovery.

Methods: A single center, propensity score-matched retrospective cohort study was designed using data from pediatric patients under 18 years old, who underwent congenital heart surgeries classified as Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) score 3 or less. The comparison was made between the HSA group, who received HSA in addition to general anesthesia (GA), and the GA group, who received GA alone. The primary outcome was the odds of patients being extubated in the operating room. Secondary outcomes included the odds of patients being extubated within 6 hours after intensive care unit (ICU) admission, as well as the length of stay (LOS) in the ICU and the hospital.

Results: A total of 566 cases were eligible for this study, with 224 cases in the HSA group and 342 cases in the GA group. Propensity score-matching yielded a total of 197 pairs of patients. The rates of extubation in the operating room and within 6 hours after ICU admission were significantly higher in the HSA group compared to the GA group [65.5% vs. 33.5%, odds ratio 3.82, 95% confidence interval (CI): 2.5 to 5.8, P<0.001; 82.7% vs. 61.9%, odds ratio 2.95, 95% CI: 1.9 to 4.7, P<0.001, respectively]. The LOS in the ICU was significantly shorter in the HSA group while there was no significant difference in the LOS in the hospital between groups (5.1 vs. 8.0 days, P<0.001; 8.7 vs. 9.5 days, P<0.60, respectively).

Conclusions: The addition of HSA to GA in fast-track pediatric congenital heart surgery was associated with increased odds of extubation in the operating room, within 6 hours of ICU admission, and with a shorter LOS in the ICU. Future randomized controlled trials are needed to confirm these results.

Background: Pulmonary embolism (PE) survivors frequently experience persistent dyspnea and diminished quality of life (QoL). Evidence suggests that rehabilitation exercise has a positive impact on QoL, physical fitness, and dyspnea in patients with heart disease and chronic obstructive pulmonary disease. However, the effects of exercise on patients with PE remain ambiguous. The purpose of our study was to systematically evaluate the impact of exercise on physical fitness and QoL in patients with PE.

Methods: PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science (WOS) databases were searched from their inception to May 21, 2024. Two reviewers independently extracted the data and evaluated the methodological quality and risk of bias in the included studies.

Results: Two studies involving 348 participants were included. This meta-analysis showed that exercise did not significantly improve the outcomes of incremental shuttle walk test (ISWT) [mean difference (MD) =60.46; 95% confidence interval (CI): -5.51, 126.42; P=0.07] or the EuroQol-5 Dimensions questionnaire (EQ-5D) (MD =0.02; 95% CI: -0.01, 0.05; P=0.14), and it did not significantly reduce pulmonary embolism quality of life (PEmbQoL) (MD =0.00; 95% CI: -0.04, 0.04; P=0.93).

Conclusions: The potential benefits of exercise programs range from no improvement in ISWT and PEmb-QoL to significant improvements in both. Implementing exercises may be valuable for patients with PE. Future meticulously designed randomized controlled trials are needed to validate these findings.

Background: Management of the intersegmental plane (ISP) remains a challenge in lung segmentectomy to minimize intra- or postoperative complications and damage to the lungs. The purpose of this study was to assess the novel method's clinical feasibility and safety for segmentectomy.

Methods: A total of 205 patients who underwent video-assisted thoracoscopic surgery (VATS) segmentectomy from May 2018 to January 2020 were retrospectively reviewed. We classified the patients into two groups according to the surgical procedure: the Inserted Multilateral Cutting Method (IMCM) group and the non-IMCM group using staplers or energy instruments to manage the ISPs. The operative characteristics and postoperative complications were compared between the two groups.

Results: All patients in the two groups underwent VATS segmentectomy with free margins. There were no significant differences in clinicopathological characteristics between the two groups. Compared with the non-IMCM group, the IMCM group was significantly associated with less intraoperative blood loss (85.5±64.3 vs. 106.6±64.7 mL; P=0.04), shorter operation time (101.7±22.2 vs. 118.3±30.9 minutes; P<0.01) and duration of chest drainage (3.8±1.3 vs. 4.2±1.4 days; P=0.03). No significant difference was found in hospital stays, prolonged air leaks, and pulmonary infection between the two groups. On multivariate analysis, the IMCM method for managing the intersegment plane was verified to be significantly correlated with lower postoperative complications (odds ratio: 0.263, P=0.01).

Conclusions: The IMCM during VATS segmentectomy showed excellent feasibility and safety and is worthy of popularization and application.

Background: Postoperative complications and extended length of stays (LOS) following lobectomy for non-small cell lung cancer (NSCLC) remain significant healthcare and economic burdens, especially in developing countries with limited resources. This study evaluated the effectiveness of enhanced recovery after surgery (ERAS) protocols in addressing these issues.

Methods: This observational study compared two groups of patients, utilizing a prospective arm for ERAS and a retrospective arm for routine care. Outcomes measured included postoperative LOS, complications, re-operations, and re-admissions. Propensity score matching (PSM) was used to adjust for potential confounders between the two groups.

Results: Among 197 NSCLC patients (98 in the ERAS group and 99 in the routine care group), the PSM resulted in 63 patients in each group. After PSM, the ERAS group experienced a significantly shorter postoperative LOS compared to the routine group (median: 4.6 vs. 5.1 days, P=0.01). There were no significant differences in postoperative complication and re-operative rates between the two groups. However, the ERAS group had a significantly lower postoperative 30-day re-admission rate of 1.6%, compared to 14.3% in the routine care group (P=0.02).

Conclusions: In NSCLC patients who underwent lobectomy, ERAS protocols improve postoperative outcomes by reducing LOS and re-admission rates. Therefore, ERAS should be considered a replacement for routine protocols in developing countries to minimize healthcare and economic burdens.

Background: For patients with early non-small cell lung cancer (NSCLC) complicated with chronic obstructive pulmonary disease (COPD), the efficacy and safety of immunotherapy are still unclear. This study was designed to investigate the effect and safety of neoadjuvant immunotherapy for patients with resectable NSCLC including those with coexisting COPD and the effect on patients' lung function.

Methods: Data of patients with resectable NSCLC who received neoadjuvant immunotherapy at the Shanghai Chest Hospital were retrospectively analyzed.

Results: A total of 57 patients were enrolled and 18 of those were with coexisting COPD. For COPD patients, the objective response rate (ORR), major pathological response (MPR), and pathological complete response (pCR) were 44.4%, 55.6%, and 38.9%, respectively, which were not statistically different from those of non-COPD patients. The 2-year event-free survival (EFS) and overall survival (OS) rates were 73.7% and 88.5%, respectively, which were lower than those of patients without COPD, but the difference was not statistically significant. After neoadjuvant immunotherapy, the ratio of forced expiratory volume in 1 second (FEV1), the ratio of FEV1 to the predicted value (FEV1%pred), forced vital capacity (FVC), and the ratio of FVC to the predicted value (FVC%pred) all improved, however, carbon monoxide diffusing capacity (DLCO) and DLCO adjusted by hemoglobin (DLCOc) were lower. For patients with COPD, only FEV1 improved after immunotherapy.

Conclusions: For resectable NSCLC patients with COPD, neoadjuvant immunotherapy could achieve better pathological response, survival benefit and improve patients' lung function.

Background: Esophageal perforation is a rare but life-threatening condition associated with a high mortality rate and often presents with nonspecific clinical manifestations that can lead to delayed diagnosis and treatment. When combined with ST-segment elevation on electrocardiography (ECG), it can be particularly challenging to distinguish esophageal perforation from acute inferior myocardial infarction, as the two conditions may share similar ECG findings.

Case description: We report the case of a 65-year-old man with a significant history of long-term alcohol consumption who presented to our hospital (the Affiliated Hospital of Liaoning University of Traditional Chinese Medicine) with persistent oppressive pain in the anterior and posterior left chest. Initially, the patient was diagnosed with acute coronary syndrome based on the ECG findings, which showed Q-wave and ST-segment elevation in the inferior leads. However, further dynamic monitoring of myocardial necrosis markers, including myoglobin and troponin I, yielded negative results inconsistent with acute myocardial infarction. Subsequent enhanced computed tomography revealed thickening and discontinuity of the wall of the thoracic esophagus with an irregular, mixed-density shadowing of the surrounding soft tissue confirming the diagnosis of esophageal rupture. Despite prompt recognition and transfer to a hospital with surgical capabilities, the patient tragically succumbed to esophageal rupture and hemorrhage while awaiting surgery.

Conclusions: This case highlights the importance of maintaining a broad differential, including esophageal rupture, in patients exhibiting necrotic Q waves and ST-segment elevation in the inferior wall of the ECG, especially in the absence of reciprocal changes in the lateral leads and the lack of abnormal markers of myocardial necrosis. Prompt recognition of this rare but potentially fatal condition is crucial for initiating appropriate treatment and improving patient outcomes. Emergency physicians should be aware of this atypical presentation of esophageal perforation mimicking an acute myocardial infarction and consider this differential diagnosis when faced with discordant clinical and diagnostic findings.

Background: Intraoperative hypothermia (IOH) has a high incidence in lung transplantation, which is considered to be an important factor affecting perioperative morbidity and mortality. Therefore, it is crucial to prevent IOH during lung transplantation. This study aimed to identify risk factors for IOH in patients receiving lung transplants, and to develop a risk model for predicting IOH.

Methods: We collected data on 160 patients who received lung transplants at The First Affiliated Hospital, Guangzhou Medical University between January 2019 and October 2023. The patients were divided into a hypothermic group (n=106) and non-hypothermic group (n=54) based on whether or not they developed IOH. We built a logistic regression model and used a nomogram to investigate the risk of IOH. The predictive power of the model was evaluated using the receiver operating characteristics (ROC) curve and the calibration curve.

Results: The incidence rate of IOH was 66.25%. Volume of intraoperative fluid [odds ratio (OR) =1.001, 95% confidence interval (CI): 1.000649 to 1.002, P<0.001] was associated with increased risk of developing IOH during lung transplantation, while extracorporeal membrane oxygenation (ECMO) (OR =0.091, 95% CI: 0.036 to 0.229, P<0.001) and circulating-water mattress (OR =0.389, 95% CI: 0.178 to 0.852, P=0.02) were protective factors against IOH. Compared to normothermic patients, patients with IOH were associated with the occurrence of cardiac arrhythmias, but was no difference in the length of stay (LOS) in the intensive care unit (ICU), acute kidney injury (AKI), postoperative hemorrhage, or 30-day mortality. The Hosmer-Lemeshow test yielded a P value of 0.18. The area under the ROC curve was 0.820, indicating that the model had good diagnostic efficacy. Similarly, evaluation of the nomogram using a calibration curve showed that the model had good accuracy in predicting IOH.

Conclusions: Owing to its strong predictive value, this risk prediction model can be used as a guide in clinical practice for screening individuals at high risk of IOH during lung transplantation.