Thoracic and Cardiovascular Surgeon最新文献

Introduction: Cardioplegia, a therapy designed to induce reversible cardiac arrest, revolutionised cardiovascular surgery. Among the various pharmacological approaches is the histidine-tryptophan-ketoglutarate (HTK) solution. Despite numerous studies, no meta-analysis has investigated the efficacy of the HTK solution in the paediatric population. Therefore, we aim to conduct a meta-analysis comparing HTK and other cardioplegia solutions in paediatric patients undergoing cardiovascular surgery.

Methods: PubMed, Embase and Cochrane databases were searched from inception through April 2024. Endpoints were computed in odds ratios (OR) with 95% Confidence Intervals (CI) for dichotomous variables, whereas continuous variables were compared using mean differences (MD) with 95% CI.

Results: 11 studies comprising 1,349 patients were included, of whom 677 (50.19%) received HTK cardioplegia. The results were similar between groups regarding mortality (OR 0.98; 95% CI 0.29, 3.29), length of hospital (MD 0.32 days; 95% CI -0.88, 1.51), MV (MD -17.72 hours; 95% IC -51.29, 15.85), arrhythmias (OR 1.27; 95% CI 0.83, 1.95;) and delayed sternal closure (OR 0.89; 95% 0.56, 1.43). However, transfusion volume was lower in the HTK group (MD -452.39; 95% CI -890.24, -14.53; p=0.04).

Conclusion: The use of HTK solution was demonstrated to be similar regarding its clinical efficacy to other approaches for cardioplegia, and it may present advantages to patients prone to hypervolemia.

Objective:  The aim of this study was to prospectively evaluate the feasibility and safety of intraoperative invasive coronary angiography (ICA) following coronary artery bypass grafting using a mobile angiography C-arm.

Methods:  Between August 2020 and December 2021, 18 patients were enrolled for intraoperative ICA following coronary artery bypass grafting. After skin closure, ICA was performed including angiography of all established bypass grafts via a mobile angiography system by an interventional cardiologist. Data on graft patency, stenosis, and kinking were assessed. Grafts were rated on an ordinal scale ranging from very poor (1) to excellent (5). Furthermore, the impact of ICA compared with flow measurement was assessed using the ordinal Likert scale ranging from (I) worse to (V) much better.

Results:  The ICA was considered better (V) compared with transient flow measurement in 38 (93%) and comparable (III) in 3 (7%) distal anastomoses. ICA impacted clinical or surgical decision-making in three patients (17%). In one patient, dual antiplatelet therapy for 6 months was initiated and rethoracotomy was needed in two (11%) patients with bypass graft revision and additional bypass grafting for graft occlusion. There were no cerebral and distal embolic events or access vessel complications observed and no postoperative acute kidney injury occurred.

Conclusion:  Intraoperative angiography after coronary bypass grafting is safe. Using a mobile angiographic device, graft patency, and function assessment was superior to transit time flow measurement leading to further consequences in a relevant number of patients. Therefore, it has the potential to reduce postoperative myocardial injury and improve survival.

Introduction: Lactate dehydrogenase (LDH) is a standard postoperative marker for hemolysis in the presence of paravalvular leakage (PVL) after aortic valve replacement (AVR). LDH is elevated in certain valves by a fluttering phenomenon. Previous studies suggested a correlation between microparticles (MP) and LDH elevation after AVR. We analyze the postoperative relevance of LDH after AVR with transapical transcatheter aortic valves (TA-TAV) or rapid deployment valves (RDV).

Method: We retrospectively analyzed the data from patients who received an AVR with RDV and TA-TAV groups between 2015-2018. We compared PVL and LDH levels before and after surgery, transvalvular gradients, heart block that required pacemaker implantation, and 30-day mortality.

Results: 138 consecutive patients were selected: 79 patients in the RDV group (37 Sorin Perceval valve, 42 Edwards Intuity valves) and 59 in the TA-TAV group (Edwards Sapien valve). TA-TAV-group were older (median 10 years) and with higher incidence of PVL (Odds ratio 11, 95% CI from 2.5 - 73.2, p-value 0.04)). TA-TAV-Group showed lower levels of LDH despite higher rates of PVL while the Perceval valve trended towards higher LDH values. Additionally, the RDV group showed an increased arrhythmia profile (p=0.0041) although the results show lower incidence in pacemaker implantation (95 % CI 0.05 - 1.65, p=0.635). 30-day mortality was similar between groups.

Conclusion: Our data do not support the association between hemolysis and PVL despite elevated LDH in suture-free valves. LDH could be a marker of extreme heart muscle output or fluttering phenomena and not a marker of hemolysis after sutureless AVR.

Objective: The goal of this study is to examine early and Mid-term results after surgical treatment of acute DeBakey type I aortic dissection (AIAD) and the effect of the range of aortic arch replacement on overall survival and prevention of distal aortic events.

Methods: Between March 2002 and July 2020, a total of 374 AIAD aortic repairs were reviewed. One hundred fifty-four (41.2%) patients had total arch replacement (TAR), while 220 (58.8%) had hemi- or partial arch replacement (PAR).

Results: Operative mortality did not show a significant difference (7.7% in PAR, 13.0 % in TAR, p = 0.096). Survival at 5 years showed no difference (77.8% in TAR, 72.6% in PAR, p = 0.14). Freedom from reoperations and re-interventions, as well as composite aortic events in the distal aorta, were comparable across groups (p=0.21, 0.84, and 0.91, respectively). The inverse provability of treatment weighting-adjusted model displayed higher 5-year freedom from reoperations and aortic events in the TAR group (p = 0.029 and 0.054, respectively) Conclusion: The extent of Arch replacement is determined based on the patient's background, making it difficult to compare the superiority of both surgical methods. However, TAR for appropriately selected patients may provide the benefit of avoiding aortic events in the long-term.

Objective: To determine the impact of symptom-to-surgery time on mortality in acute type A aortic dissection (ATAAD) patients, with and without malperfusion.

Methods: A retrospective analysis of 288 ATAAD patients was conducted. Patients were separated into the early (≤ 10 h) and late (> 10 h) groups by symptom-to-surgery time. Data on characteristics, surgery, and complications were compared, and multivariable logistic regression determined mortality risk factors.

Results: Mortality rates did not significantly differ between early and late groups. Age (OR 1.09, 95% CI 1.05-1.13, p<0.001), ECMO use (OR 10.73, 95% CI 2.51-45.87, p=0.001), and malperfusion (OR 6.83, 95% CI 2.84-16.45, p<0.001) predicted operative death. Subgroup analysis showed cerebral (OR 3.20, 95% CI 1.11-9.26, p=0.031), cardiac (OR 5.89, 95% CI 1.32-26.31, p=0.020), and limb (OR 6.20, 95% CI 1.75-22.05, p=0.005) malperfusion as predictors of operative death. One (OR 6.30, 95% CI 2.39-16.61, p<0.001), two (OR 12.79, 95% CI 2.74-59.81, p=0.001), and three (OR 46.99, 95% CI 7.61-288.94, p<0.001) organs malperfusion, together with Penn B (OR 7.96, 95% CI 3.04-20.81, p<0.001) and Penn B-C (OR 12.50, 95% CI 2.65-58.87, p=0.001) classifications predict operative mortality. Survival analysis revealed significant differences between malperfusion and no malperfusion (34% vs. 9%, p<0.001) but not between late and early (14% vs. 21%, p=0.132) groups. Malperfusion remained an essential predictor of operative (OR 7.06 95% CI 3.11-17.19, p<0.001) and mid-term mortality (OR 3.38 95% CI 1.97-5.77, p<0.001) in subgroup analysis.

Conclusions: Preoperative malperfusion status, rather than symptom-to-surgery time, significantly impacts both operative and mid-term mortality in ATAAD patients.

Background: There is uncertainty regarding the impact of high-intensity statins on postoperative outcomes in patients undergoing surgical myocardial revascularization. This study was conducted to evaluate the impact of high-intensity statin treatment on the occurrence rate of new-onset postoperative atrial fibrillation (POAF) after off-pump coronary artery bypass grafting (OPCAB).

Methods: Six hundred thirteen patients (66.8±9.8 years, male:female = 476:137) who underwent isolated OPCAB were retrospectively enrolled. Hypertension (n = 409, 66.7%), diabetes mellitus (n = 343, 59.6%) and chronic kidney disease (n = 138, 22.5%) were common comorbidities. Statins and beta-blockers were administered to all patients until the day of surgery and resumed within 6 hours after surgery. Risk factors associated with POAF were analyzed, including the use of high-intensity statins (atorvastatin 40 mg-80 mg or rosuvastatin 20 mg), as well as baseline characteristics and preoperative risk factors.

Results: High-intensity statins were used in 158 patients (25.8%). POAF occurred in 184 patients (30.0%). The use of high-intensity statins was not correlated with preoperative levels of low-density lipoprotein (P = 0.135) or high sensitivity C-reactive protein (P = 0.365). Multivariate logistic regression analysis revealed that the use of high-intensity statins was significantly associated with a reduced occurrence of POAF (P = 0.022, odds ratio [95% confidence interval] = 0.592 [0.378-0.926]). Age, acute coronary syndrome, insulin-dependent diabetes mellitus and chronic kidney disease were also significantly associated with POAF.

Conclusion: Preoperative administration of high-intensity statins was associated with a 41% reduction in the occurrence rate of POAF in patients who underwent OPCAB.

Background: İschemic 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 end point was the remaining ischemic mitral regurgitation 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 among with concomitant moderate IMR. The mean follow-up period was 19.4±21.6 months. The median number of the coronary anastomosis was 4(range.1-6). In 58.06% (n=36), the regurgitation regressed. Left atrial (LA) diameter significantly decreased postoperatively (p= .040). Increased LA diameter was associated with increased major adverse events (p=.010). Rehospitalization rates were higher in low EF. The postoperative poor functional status(NYHA III-IV) was correlated with increased postoperative left ventricular end-systolic diameter (41.75±6.13 v.s. 34.79±6.8 p=.05). Mortality(4.8%, n=3) was associated with elder age and increased preoperative systolic pulmonary artery pressure (p= .050; p= .046 respectively).

Conclusion: LA diameter, LVESD, mean systolic pulmonary artery pressure, LVEF and age are important predictors for outcomes in IMR. Remaining IMR per se is not directly correlated with increased mortality and MACCE. Facile stabilization technique we use here, is advantegous due to the feasibility of full revascularization of all intended vessels particularly of the inferoposterior wall by providing an excellent vision without compression of the heart.

Objectives: In patients who underwent surgical septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM), additional mitral valve repair may offer additional benefits in terms of further reducing left ventricle 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.

Methods: 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.

Results: From 1911 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 mmHg (95% CI: 76-91). The postoperative pooled mean LVOT-gradient was 11 mmHg (95% CI: 10 - 12) with a low heterogeneity (I2 = 44%). The residual LVOT gradient exceeding 30 mmHg was present in 9 (1%) patients. MR-grade 3 or 4 at hospital discharge was present in 7 (1%) patients. The 30-day new permanent pacemaker implantation rate was 7% and the in-hospital mortality was 0.4%.

Conclusion: This systematic review and meta-analysis demonstrate that combining surgical septal 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.

Background:  The possibility of coil dislocation in computed tomography (CT)-guided microcoil localization of superficial pulmonary nodules is relatively high. The aim of the study is to investigate the outcomes of deeper localization technique during CT-guided microcoil localization of superficial pulmonary nodules before video-assisted thoracoscopic surgery (VATS).

Methods:  Fifty-seven identified superficial pulmonary nodules (nodule-pleural distance ≤ 1 cm on CT image) from 51 consecutive patients underwent CT-guided microcoil localization, and subsequent VATSs were included. The rate of technical success, complications, and excised lung volume were compared between deeper localization technique group and conventional localization technique group.

Results:  The technical success rate of the localization procedure was 100% (25/25) in the deeper localization group and 81.3% (26/32) in the conventional localization group (p = 0.030). Excluding one case of lobectomy, the excised lung volume in the deeper localization group and the conventional localization group was 39.3 ± 23.5 and 37.2 ± 16.2 cm³, respectively (p = 0.684). The incidence of pneumothorax was similar between the deeper localization group and the conventional localization group (24.0 vs. 21.9%, respectively, p = 0.850). The incidence of intrapulmonary hemorrhage in the deeper localization group was higher (16.0%) than that in the conventional localization group (6.3%), but the difference was not statistically significant (p = 0.388).

Conclusion:  CT-guided microcoil localization of superficial pulmonary nodules prior to VATS using a deeper localization technique is feasible. Deeper localization technique reduced the occurrence of dislocation but did not increase excised lung volume.