Thoracic and Cardiovascular Surgeon最新文献

The left internal mammary artery (LIMA) remains the preferred conduit for coronary artery bypass grafting (CABG). However, diabetic patients face an increased risk of deep sternal wound infection (DSWI), particularly after pedicled LIMA harvesting, which may impair sternal perfusion. Skeletonized harvesting preserves sternal vascularity and may reduce infection risk, but current evidence remains limited and inconsistent.Three different databases were assessed. The primary outcome was the occurrence of DSWI. Secondary outcomes were hospital length of stay (LOS), cardiopulmonary bypass (CPB) time, blood transfusion rates, and aortic cross-clamp time. A random effects model was performed.Three retrospective studies involving 400 diabetic patients were included, of whom 190 underwent skeletonized and 210 pedicled LIMA harvesting. Skeletonized harvesting was associated with significantly reduced risk of DSWI (odds ratio [OR]: 0.25; 95% confidence interval [CI]: 0.07-0.88; p = 0.031). CPB (mean difference [MD]: 3.03 minutes; 95% CI: 1.18-4.88; p = 0.001) and aortic cross-clamp times (MD: 3.06 minutes; 95% CI: 2.03-4.10; p < 0.001) were slightly longer in the skeletonized group. No significant differences were observed in hospital LOS (p = 0.159) or blood transfusion requirements (p = 0.959).Skeletonized LIMA harvesting is associated with lower odds of DSWI in diabetic patients undergoing CABG, despite modestly longer operative times.

Left atrial enlargement is a well-recognized marker of adverse cardiovascular outcomes, but its impact on early morbidity and mortality after valve replacement remains uncertain.We retrospectively reviewed 422 patients who underwent aortic and/or mitral valve replacement (MVR) for rheumatic heart disease at X between 2004 and 2022. Preoperative left atrial diameter index (LADI) was measured, and patients were classified as normal (<2.3 cm/m²) or abnormal (≥2.3 cm/m²). Clinical, operative, and postoperative outcomes were compared. The primary endpoint was 30-day all-cause mortality; secondary endpoints included postoperative atrial fibrillation (POAF), neurological events, renal impairment, re-exploration for bleeding, and intraoperative pacing wire requirement.Nearly half of patients (48.8%) had abnormal LADI. Patients with enlarged atria were more often female, had smaller body size, and were significantly more likely to undergo MVR (42.7% versus 18.1%, p < 0.001). Abnormal LADI was strongly associated with POAF (16.0% versus 7.4%, p = 0.006) and intraoperative pacing wire insertion (38.3% versus 23.5%, p = 0.001). Multivariate analysis confirmed severe LADI as an independent predictor of POAF (OR 3.91, p = 0.001) and pacing requirements (OR 2.31, p = 0.004). No significant differences were observed in 30-day mortality, stroke/transient ischemic attack, renal dysfunction, or bleeding complications.Preoperative LADI is an independent predictor of postoperative arrhythmic complications and pacing needs after valve replacement, but not early mortality. Incorporating LADI into preoperative risk assessment may improve rhythm surveillance and perioperative planning. Future prospective studies should evaluate its long-term prognostic value and role in reverse remodeling after surgery.

Aortic annular enlargement has become an essential component of contemporary aortic valve surgery, particularly in the context of patient-prosthesis mismatch. We describe several practical technical adaptations to a Y-incision-based annular enlargement approach, derived from our institutional experience. These modifications focus on patch material selection, suturing strategy, and external reinforcement, with the aim of simplifying execution and enhancing hemostatic reliability while preserving the conceptual framework of the technique.

Endoscopic graft harvesting was first introduced clinically in the 1990s and is currently used in 80-90% of all CABG cases in the United States. Several studies have compared open and endoscopic harvesting techniques in terms of long-term clinical outcomes and major adverse events. In summary, endoscopic graft harvesting allows for reduced postoperative pain, minimization of wound infection risk and a better cosmetic result with higher patients' satisfaction. Harvester experience guarantees a graft quality that is comparable to open harvesting techniques. Thus, American as well as European guidelines recommend endoscopic harvesting - particularly in patients at high risk of wound healing disorders.

Compensatory hyperhidrosis remains the most significant complication after endoscopic thoracic sympathectomy (ETS) for primary palmar hyperhidrosis. However, its temporal evolution and long-term predictors are not fully elucidated.This multicenter retrospective study included 226 patients who underwent bilateral clip-based ETS between 2009 and 2023. Patients were stratified by surgical level: R3 (n = 60), R4 (n = 72), R2-R4 (n = 81), and asymmetric interruption (n = 13). Compensatory hyperhidrosis severity was assessed at 6 and 12 months, and final follow-up (mean 98 months). Logistic regression identified independent predictors of compensatory hyperhidrosis, recurrence, and patient satisfaction.Complete palmar dryness was achieved in 84.5% of patients. Compensatory hyperhidrosis occurred in 48.7%, exclusively within the first 6 postoperative months, with no late-onset cases. During long-term follow-up, spontaneous regression of compensatory hyperhidrosis was observed in 28.2% of affected patients. Compensatory hyperhidrosis incidence differed significantly across surgical levels (p = 0.011): 38.3% (R3), 55.6% (R4), 63.0% (R2-R4), and 30.8% (asymmetric). Multivariate analysis confirmed multi-level R2-R4 sympathectomy as an independent predictor of compensatory hyperhidrosis (OR = 2.18, p = 0.042), while single-level R4 interruption provided the lowest persistent compensatory hyperhidrosis burden. Overall satisfaction was 79.6%, and recurrence-not compensatory hyperhidrosis-was the main determinant of dissatisfaction (OR = 2.48, p < 0.001). Smoking history independently predicted recurrence (OR = 2.09, p = 0.042).Compensatory hyperhidrosis develops exclusively during the early postoperative period and shows partial spontaneous improvement over time. Multi-level interruption significantly increases compensatory hyperhidrosis risk without improving efficacy, supporting limited single-level approaches (preferably R4). These findings emphasize the importance of surgical level selection, smoking cessation, and realistic postoperative counseling.

Infective endocarditis (IE) is associated with extremely high surgical mortality. During the SARS-CoV-2 pandemic, hospitals restructured their intensive care units and outpatient services to prioritize COVID-19 care, which may have affected the outcomes of patients requiring urgent procedures. This study aimed to evaluate the impact of the pandemic on surgical outcomes of IE patients in Southern Germany.This observational, community-based study compared two cohorts of surgical candidates: a pandemic cohort from March 2020 to November 2021 (n = 84) and a pre-pandemic cohort from August 2018 to March 2020 (before the lockdown, n = 94). Preoperative status and postoperative in-hospital complications were analyzed and compared between the groups.The pandemic cohort experienced longer symptom onset to diagnosis intervals (14.5 versus 8 days, p = 0.529). A higher incidence of definite IE was observed after the lockdown according to the modified Duke criteria (82.1% versus 68.1%, p = 0.035). Patients presented with more severe symptoms post-lockdown (NYHA Class III: 50% versus 33%; Class IV: 22.6% versus 11.7%, p = 0.001). Postoperative complications, such as re-thoracotomy due to bleeding and hemofiltration for acute renal failure, were significantly more frequent after the lockdown (p < 0.05). However, in-hospital survival rates did not differ significantly between the groups.The COVID-19 pandemic and related lockdown measures were associated with delayed diagnoses and worse perioperative outcomes for surgical IE patients, highlighting the need for improved management strategies during public health crises.

Multiple arterial grafting (MAG) is associated with improved long-term outcomes. However, there are limited data on the benefit of total arterial revascularization (TAR).Retrospective study of adult patients with multivessel disease undergoing isolated coronary artery bypass grafting (CABG) in three centers between January 1, 2009, and December 31, 2023. Patients were grouped according to the revascularization strategy (TAR vs. MAG). The primary outcome was a composite of major adverse cardiac and cerebrovascular events (MACCE). The cumulative incidence of MACCE was plotted using Kaplan Meier (KM) curves. The hazard ratio (HR) for TAG versus MAG was calculated using multivariate Cox models.Our cohort included 2,791 patients. About 1,048 (37.55%) underwent TAR and 1,743 (62.45%) underwent MAG, of whom 2,434 (87.21%) were male. Mean age was 61.6 ± 9.8 years in the TAR and 62.1 ± 9.1 years in the MAG. Median follow-up time was 101 months. The cumulative incidence of the primary outcome was 48.57% in the TAR and 42.4% in the MAG group. After multivariable adjustment, TAR had an HR of 1.05, 95% CI (0.93-1.18) for the primary outcome (p = 0.25). The mortality rate was 28.72% in the TAR and 23.06% in the MAG group.TAR showed no benefit over MAG at midterm follow-up.

This study evaluated the midterm outcomes of rapid deployment aortic valve replacement (RDAVR) performed regardless of pathology for various aortic valve diseases at a single center.Of the 344 patients who underwent RDAVR using Edwards INTUITY during the study period at our institution, 176 had bicuspid valve diseases (51.2%), 20 had pure aortic regurgitation (5.8%), and 4 had infective endocarditis (1.2%). Median follow-up duration was 28.6 months (maximum: 86.4 months). Midterm clinical outcomes were evaluated, and the changes of valve hemodynamics from early postoperative period to 5 years after surgery were also investigated.Mean age was 68.9 ± 9.8 years, and 46.2% of the patients were female. Isolated RDAVR was performed in 90 patients (26.2%), and concomitant procedures, including aortic surgery (48.8%), mitral valve surgery (20.3%), arrhythmia surgery (9.0%), tricuspid valve surgery (7.0%), and coronary artery bypass grafting (5.5%), were performed in 254 patients (73.8%). Operative mortality occurred in 11 patients (3.2%), and permanent pacemaker implantation was required in 5 patients (1.5%) in early postoperative period. Overall survival rate was 86.9% at 5 years, and cumulative incidence of cardiac death was 6.3% at 5 years. No deterioration of valve hemodynamics was observed at midterm echocardiographic evaluation in either the overall population or for each size of valve.Isolated or concomitant aortic valve replacement using rapid-deployment valves was performed for various aortic valve diseases regardless of the underlying pathology at our institution, and the clinical and hemodynamic outcomes were excellent for up to 5 years.