Thoracic and Cardiovascular Surgeon最新文献

Background:  Coronary artery bypass grafting (CABG) is one of the revascularization modalities available in patients with left ventricular dysfunction (LVD). Multiple arterial grafting (MAG) is associated with improved long-term outcomes. Data on the benefits of MAG in patients with LVD are limited. We examined the effect of MAG on outcomes across the spectrum of left ventricle (LV) function.

Methods:  Retrospective cohort study of patients undergoing isolated CABG (January 1, 2009, to October 1, 2021). Patients were grouped according to revascularization strategy (single vs. MAG). The primary outcome was a composite of all-cause mortality, cerebrovascular accident, myocardial infarction, and repeat revascularization (major adverse cardiac and cerebrovascular events [MACCE]). The cumulative incidence of MACCE was plotted using Kaplan-Meier curves. Results were stratified according to LV function (<30%, 30-50%, >50%).

Results:  Our cohort included 4,763 patients; 1,976 (41.4%) underwent single arterial grafting (SAG), and 2,787 (58.6%) underwent MAG; 3,976 (83.4%) were male with a median age of 64 (interquartile range [IQR] 57-71) years. Distribution of LV function was 2,539 (53.3%) with an ejection fraction (EF) >50%, 1,828 (38.3%) with an EF of 30-50%, and 396 (8.3%) with an EF <30%. Median follow-up time was 64 (37-102) months. Cumulative incidence of MACCE at 72 months was 28.7% in the MAG and 30.3% in the SAG group. Stratified by LV function, the hazard ratio for MACCE at 160 months was 0.71 (95% CI 0.54-0.93), 0.78 (95% CI 0.68-0.9), and 0.95 (95% CI 0.83-1.09) for LV function <30%, 30-50%, >50%, respectively, with no significant interaction between MAG and LV function.

Conclusion:  MAG is associated with improved outcomes following CABG across the spectrum of LV function.

Background:  Respiratory muscle strength affects pulmonary function after lung resection; however, the role of diaphragm density, an emerging index of muscle quality, remains unexplored. We investigated the role of crural diaphragm density (CDD) in respiratory complications (RC) after video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer.

Methods:  A total of 118 patients were retrospectively enrolled between 2015 and 2022. Exclusion criteria were neoadjuvant therapy, thoracic trauma, and previous cardiothoracic and abdominal surgery. Demographic, functional, and radiological data were collected. The CDD in Hounsfield Unit (HU) was defined as the average of the density of the right and left crural diaphragm at the level of the median arcuate ligament on computed tomography axial images. RC included sputum retention, respiratory infections, atelectasis, pneumonia, respiratory failure, and acute respiratory distress syndrome.

Results:  The prevalence of postoperative RC was 41% (48 of 118). RC occurred mostly in males (64.6 vs. 44.3%, p = 0.04), current smokers (41.7 vs. 21.4%, p = 0.02), a longer surgical procedure (210 vs. 180 minutes, p = 0.04), and a lower CDD (42.5 vs. 48 HU, p = 0.05). The optimal cutoff of CDD was 39.75 HU (sensitivity 43%, specificity 82%, accuracy 65%, area under the curve: 0.62, p = 0.05), slightly above the threshold for reduced muscle mass (<30 HU). By multivariable logistic regression a CDD ≤ 39.75 HU (hazard ratio [HR]: 3.134 [95% confidence interval, CI: 1.111-8.844], p = 0.03) and current smoking (HR: 2.733 [95% CI: 1.012-7.380], p = 0.05) were both independent risk factors of postoperative RC.

Conclusion:  The CDD seems to be a simple and useful tool for predicting RC after VATS lobectomy, especially among current smokers. Such patients, identified early, could benefit from preoperative functional and nutritional rehabilitation.

Background:  Coronary artery disease (CAD) limits life expectancy compared to the general population. Myocardial infarctions (MIs) are the primary cause of death. The incidence of MI increases progressively with age and most MI deaths occur in the population older than 70 years. Coronary artery bypass grafting (CABG) may prevent the occurrence of new MIs by bypassing most CAD lesions, providing downstream "collateralization" to the diseased vessel, and consequently prolonging survival. We systematically assessed the survival-improving potential of CABG by comparing elderly CABG patients to the age-matched general population.

Methods:  Three databases were assessed. The primary and single outcome was long-term all-cause mortality. Time-to-event data of the individual studies were extracted and reconstructed in an overall survival curve. As a sensitivity analysis, summary hazard ratios (HRs) and 95% confidence intervals (CIs) for all individual studies were pooled and meta-analytically addressed. The control group was based on the age-matched general population of each individual study.

Results:  From 1,352 records, 4 studies (4,045 patients) were included in the analysis. Elderly patients (>70 years) who underwent CABG had a significantly lower risk of death in the follow-up compared to the general age-matched population in the overall survival analysis (HR: 0.88; 95% CI: 0.83, 0.94; p < 0.001: mean follow-up was 7 years).

Conclusion:  Elderly patients who undergo CABG appear to have significantly better long-term survival compared to the age-matched general population. This advantage becomes visible after the first year and underscores the life-prolonging effect of bypass surgery, which may eliminate the expected reduction in life expectancy through CAD.

Background:  Ischemic mitral regurgitation (IMR) is associated with high mortality and poor outcomes. The surgical management of moderate IMR is still an object of debate.

Methods:  Patients with moderate IMR who underwent isolated off-pump coronary bypass grafting (OPCAB) with facile stabilization between January 2015 and February 2022 were analyzed. The primary endpoint was the remaining IMR and echocardiographic findings while the secondary outcomes were defined as mortality, major adverse events, and postoperative functional status.

Results:  Of 541 patients who underwent isolated OPCAB in this period, there were 62 patients with concomitant moderate IMR. The mean follow-up period was 19.4 ± 21.6 months. The median number of the coronary anastomosis was 4. In 58.06% (n = 36), the regurgitation regressed. Left atrial (LA) diameter significantly decreased postoperatively (p = 0.040). Increased LA diameter was associated with increased major adverse events (p = 0.010). Rehospitalization rates were higher in low ejection fraction (EF). The postoperative poor functional status (New York Heart Association [NYHA] III-IV) was correlated with an increased postoperative left ventricular end-systolic diameter (LVESD; 41.75 ± 6.13 vs. 34.79 ± 6.8 mm, p = 0.05). Mortality (4.8%, n = 3) was associated with older age and increased preoperative systolic pulmonary artery pressure (PAP; p = 0.050 and p = 0.046, respectively).

Conclusion:  LA diameter, LVESD, mean systolic PAP, left ventricular ejection fraction (LVEF), and age are important predictors for outcomes in IMR. Remaining IMR per se is not directly correlated with increased mortality and major adverse cardiac and cerebrovascular events. The facile stabilization technique we used appears to be advantageous due to the feasibility of full revascularization of all intended vessels, particularly of the inferoposterior wall by providing excellent vision without compression of the heart.

Background:  Although advancements in the management of thoracic aortic disease have led to a reduction in acute mortality, individuals requiring postoperative reintervention experience substantially worse long-term clinical outcomes and increased mortality. We aimed to identify the risk factors for postoperative reintervention in this high-risk population.

Patients and methods:  This prospective observational cohort study included patients who survived endovascular or open surgical treatment for thoracic aortic disease between January 2009 and June 2020. We excluded those with inflammatory or traumatic thoracic aortic diseases. The risk factors were identified using multivariate logistic regression and Cox proportional hazards regression models.

Results:  The study included 95 genetically tested patients aged 54.13 ± 12.13 years, comprising 67 men (70.53%) and 28 women (29.47%). Primary open surgery was performed in 74.7% and endovascular repair in 25.3% of the patients. Of these, 35.8% required one or more reinterventions at the time of follow-up (3 ± 2.5 years, mean ± standard deviation). The reintervention rate was higher in the endovascular repair group than in the open repair group. Among the potential risk factors, only residual aortic dissection emerged as an independent predictor of reintervention (odds ratio: 3.29, 95% confidence interval: 1.25-8.64).

Conclusion:  Reintervention after primary thoracic aortic repair remains a significant clinical issue, even in high-volume tertiary centers. Close follow-up and personalized care at aortic centers are imperative. In our cohort of patients with thoracic aortic disease undergoing open or endovascular surgery, postoperative residual dissection was independently associated with the necessity of reintervention, emphasizing the importance of intensified clinical monitoring in these patients.

Background:  The aim of this study is to compare the insertion sites of drainage tubes placed in the left thorax after elective coronary artery bypass grafting surgeries.

Materials and methods:  Patients were divided into two groups based on the site of tube insertion into the left hemithorax: those with a tube inserted from the subxiphoid region and those with a tube inserted from the left intercostal region. Comparative analyses between these two groups and factor analyses contributing to the outcome were performed.

Results:  There were no significant differences observed in terms of age, gender, height, and weight among patients undergoing coronary artery bypass surgery based on the site of drain placement. Twelve patients (5.2%) required re-drainage procedures, with 5 (41.7%) for pneumothorax and 7 (58.3%) for pleural effusion. Atelectasis was absent in 144 patients (62.1%) while present in 88 patients (37.9%). The frequency of atrial fibrillation was significantly higher in the group with intercostal drains. Additionally, pain scale scores were significantly higher in patients with intercostal drains. Path analysis revealed that the visual pain scale value played a full mediating role in the effect of drain site on atrial fibrillation.

Conclusion:  The statistically significant occurrence of pain and higher rates of postoperative atrial fibrillation in patients with intercostal tube placement are noteworthy. We believe that in patients undergoing elective coronary artery bypass surgery, the drain placed in the left hemithorax should be inserted from the subxiphoid region, if there are no contraindications.

In patients who underwent surgical myectomy for hypertrophic obstructive cardiomyopathy (HOCM), additional mitral valve repair may offer additional benefits in terms of further reducing left ventricular outflow tract (LVOT) gradients, systolic anterior motion (SAM), and mitral regurgitation (MR). We performed a systematic review of the literature to evaluate the evidence of surgical myectomy with additional secondary chordal cutting in patients with HOCM. A systematic literature search in MEDLINE and EMBASE was performed until April 2024. The primary outcome studied was postoperative echocardiographic LVOT gradient. A random effects meta-analysis of means was performed for the primary outcome. The secondary outcomes studied were postoperative residual MR grade, 30-day new permanent pacemaker implantation, and in-hospital mortality. From 1,911 unique publications, a total of 6 articles fulfilled the inclusion criteria and comprised 471 patients with a pooled mean preoperative resting LVOT gradient of 84 mm Hg (95% confidence interval [CI]: 76-91). The postoperative pooled mean LVOT gradient was 11 mm Hg (95% CI: 10-12) with a low heterogeneity (I ² = 44%). The residual LVOT gradient exceeding 30 mm Hg was present in nine (1%) patients. MR grade 3 or 4 at hospital discharge was present in seven (1%) patients. The 30-day new permanent pacemaker implantation rate was 7% and the in-hospital mortality was 0.4%. This systematic review and meta-analysis demonstrate that combining surgical myectomy with secondary chordal cutting can be performed safely and effectively eliminate LVOT obstruction in HOCM patients. Further studies are needed to determine the additive effectiveness of additional secondary chordal cuttings.

Aortic valve replacement improves and prolongs lives of patients with aortic valve disease, but requires significant healthcare resources, which are mainly determined by the length of associated hospital stays. Therefore, this study aims to identify risk factors for extended length of stay after surgical aortic valve replacement. Between 2018 and 2023, 458 consecutive patients underwent isolated surgical aortic valve replacement at our center and were included in our analysis. To identify independent predictors for hospital and intensive care unit stay, multivariable linear regression analysis using backward elimination process was performed. Upon multivariable linear regression, endocarditis [regression coefficient (β) 2.98; 95% confidence interval (CI) 1.51, 4.45; p<0.001)] and prior aortic valve surgery (β 1.72; 95% CI 0.18, 3.26; p=0.029) were associated with prolonged hospital stay. Prior aortic valve surgery was associated with prolonged intensive care unit stay (β 0.99; 95% CI 0.39, 1.59; p=0.001) as well as chronic obstructive pulmonary disease (β 1.61; 95% CI 0.66, 2.55; p=0.001), smaller prosthetic valve sizes (β -0.18; 95% CI -0.30, -0.06; p=0.003), preoperative atrial fibrillation (β 1.06; 95% CI 0.32, 1.79; p=0.005), and reduced left ventricular ejection fraction (β -0.03; 95% CI -0.05, -0.01; p=0.006). Pending further validation, structured programs aiming to accelerate intensive care unit and hospital discharge after surgical aortic valve replacement should focus on patients with prior cardiac surgery, atrial fibrillation, and chronic obstructive pulmonary disease. Surgeons should aim to implant large-diameter valves. Furthermore, the identified predictors should be used to discuss surgical versus transcatheter procedures in the interdisciplinary heart team.

Background:  Difficult airway management is essential in anesthesia practice. Particular challenges are posed to patients who require intraoperative one-lung ventilation. Specific guidelines for these scenarios have been lacking. The recent update of German guidelines incorporates recommendations for securing the airway in anticipated difficult airway scenarios in patients requiring one-lung ventilation. However, scientific data on this specific topic is rare.

Methods:  A retrospective analysis was conducted on adult patients undergoing thoracic surgery with one-lung ventilation from 2016 to 2021. During these years, the standard of practice has been in line with the now published guidelines. Patients with anticipated difficult airways were identified, and airway management strategies were analyzed.

Results:  Among 3,197 anesthetic procedures, 44 cases involved anticipated difficult airways, primarily due to prior head and neck tumor treatment. Nasal bronchoscopic awake intubation followed by oral reintubation under videolaryngoscopic inspection and the use of bronchial blockers was the standard procedure. No severe complications were recorded, and one-lung ventilation was maintained successfully in all cases.

Discussion:  The study highlights the challenges of managing difficult airways during thoracic surgery. Recommendations align with recent guidelines, emphasizing the importance of tailored approaches. The use of single-lumen tubes with bronchial blockers appears favorable over double-lumen tubes, offering comparable ventilation quality with reduced risks.

Conclusion:  Despite limitations, the study underscores the safety and efficacy of tailored airway management strategies during one-lung ventilation in patients with anticipated difficult airways. The presented approach offers patient safety and practicability. Further multicenter studies are warranted to validate these findings and refine clinical approaches.

Objectives We evaluated and compared incidence and evolution of atrioventricular and intraventricular conduction disorders following rapid deployment AVR and conventional AVR. Methods 147 patients who underwent isolated rapid deployment AVR between 2017 and 2021 as well as 128 patients after conventional biological AVR in the same period were included in this study. ECGs recorded at baseline, discharge and 12 months were retrospectively analyzed. Results Patients in both groups had comparable a STS score (2.9 ± 1.6 vs 3.1 ± 2.2 p=0.32) and comparable baseline characteristics. At discharge the mean QRS width in the RDAVR group was significantly increased with 117.4  28.6 ms and a mean  QRS width of 21.7  26.3 ms (p<0.001) compared to baseline. No significant changes of QRS width were found in the AVR group with a mean value of 101.2  24.1 ms and a mean  QRS width of 3.9  23.9 ms at discharge (p=0.193). Left bundle branch block was increased in the RDAVR group after 12 months (19.3% vs 5.1% p<0.001) Permanent pacemaker implantation rates were significantly higher in the RDAVR group after 12months. (HR: 4.68; 95% CI: 2.23 - 7.43 p<0.001) Mortality did not differ in both groups after 12 months (HR: 1.09; 95% CI: 0.46 - 1.83; p = 0.835) Conclusions Patients after RDAVR showed significant higher rates of left bundle branch block with significantly increased QRS width and permanent pacemaker implantation after 12 months. However, higher mortality was not observed in the RDAVR group.