Thoracic and Cardiovascular Surgeon最新文献

Background:  Several studies have reported high rates of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) with the Mosaic prosthesis. This work assesses the incidence of PPM after AVR with a modified version of the Mosaic prosthesis, the Mosaic Ultra.

Methods:  We performed a retrospective analysis of the data of 532 patients who underwent AVR with implantation of the Mosaic Ultra prosthesis in the period 2007-2016 in our institution. Patients were classified according to their indexed effective orifice area (EOAi) to severe (EOAi < 0.65 cm²/m²), moderate (EOAi 0.65-0.85 cm²/m²), and absent/mild PPM (EOAi > 0.85 cm²/m²). In-hospital postoperative outcomes and the impact of PPM on mean transvalvular pressure gradient after stratification by prosthesis size were assessed.

Results:  Overall, 3 (0.6%) patients had severe, 92 (17.3%) moderate, and 437 (82.1%) absent/mild PPM. There was a significant difference in PPM proportions (moderate/severe vs absent/mild PPM) across different prosthesis sizes overall (p < 0.0001), observing gradually increasing rates of PPM with decreasing prosthesis sizes. Patients with moderate/severe PPM had higher mean transvalvular pressure gradients (19 [13-25] vs 13 [10-17] mm Hg, p < 0.0001) than patients with absent/mild PPM. There was a significant difference in mean transvalvular pressure gradient between the different aortic valve prosthesis sizes overall (p < 0.0001), observing gradually increasing gradients with decreasing prosthesis sizes.

Conclusion:  Patients undergoing AVR with the smaller sized (19, 21, and 23 mm) Mosaic Ultra aortic valve prostheses exhibit a higher risk for moderate/severe PPM and higher mean aortic transvalvular pressure gradients than patients receiving the larger sized (25, 27, and 29 mm) prostheses.

Background:  Bioprosthetic stentless aortic valves may degenerate over time and will require replacement. This study aimed to evaluate early- and mid-term outcomes after isolated surgical redo aortic valve replacement (redo-SAVR) and transcatheter valve-in-valve implantation (TAVI-VIV) for degenerated stentless Freestyle bioprostheses.

Methods:  We reviewed records of 56 patients at a single center. Overall, 37 patients (66.1%) received TAVI-VIV and 19 (33.9%) received redo-SAVR.

Results:  Thirty-day survival was similar in both groups (100%). One-year survival was comparable between groups (97.3% in TAVI-VIV and 100% in redo-SAVR, p = 1.0). The difference in mid-term survival after adjusting for age and EuroScore II was not significant (p = 0.41). The incidence of pacemaker implantation after TAVI-VIV was higher than after redo-SAVR (19.4% vs. 0%, p = 0.08).

Conclusion:  The 30-day and 1-year survival rates after both procedures were outstanding, irrespective of baseline characteristics. Isolated redo-SAVR should be favored in young patients, as the pacemaker implantation rate is lower. TAVI-VIV for degenerated Freestyle prosthesis can be a method of choice in elderly patients and those with high operative risk.

The patient-prosthesis mismatch has been reported as an important cause of adverse outcome following aortic valve replacement. The relief of patient-prosthesis mismatch generally requires a reoperation of comprehensive nature, which necessitates an extensive aortic root enlargement. The Konno aortoventriculoplasty represents an efficient treatment option, as this technique provides both extreme root enlargement and relief of the frequently associated subvalvular obstruction. However, the application and conduct of the procedure may somewhat differ from the pediatric Konno procedures. This article describes our surgical technique adaptation in Konno-aortoventriculoplasty for adult patient-prosthesis mismatch cases, highlighting the differing points from the pediatric-Konno.

Background:  Surgical resection is the gold standard treatment for the management of early-stage lung cancer. Several modifiable factors may significantly influence postoperative morbidity and mortality. We examined the outcomes of patients following lung resection based upon preoperative smoking status to quantify the impact on postoperative outcomes.

Methods:  Data from consecutive lung resections from January 1, 2012 to June 11, 2021 were included. Biopsies for interstitial lung disease and resections for emphysematous lung or bullae were excluded. Patients were divided into three cohorts: current smokers (those who smoked within 4 weeks of surgery), ex-smokers (those who stopped smoking prior to 4 weeks leading up to surgery), and nonsmokers (those who have never smoked). Patient's preoperative variables, postoperative complications, length of stay, and mortality were examined.

Results:  A total of 2,426 patients were included in the study. A total of 502 patients (20.7%) were current smokers, 1,445 (59.6%) were ex-smokers and 479 patients (19.7%) nonsmokers. Of those smoking immediately prior to surgery 36.9% developed postoperative complications. Lower respiratory tract infections (18.1%) and prolonged air leak (17.1%), in particular, were significant higher in smokers. 90-day mortality (5.8%) was higher in the current smokers when compared with ex- and nonsmokers (5.3 and 1%, respectively). Median length of hospital stay, readmissions, and cost of hospital stay was also higher in the current smoker cohort.

Conclusion:  Smoking immediately prior to surgery is associated with an increase in morbidity, mortality, and length of stay. Not only does this have a significant individual impact, but it is also associated with a significant financial burden to the National Health Service.

Background:  Mediastinal lymphadenopathies with high 18-fluorodeoxyglucose uptake in patients previously operated on for lung cancer are alarming for recurrence and necessitate invasive diagnostic procedures. Peroperative placement of oxidized cellulose to control minor bleeding may lead to a metastasis-like image through a foreign body reaction within the dissected mediastinal lymph node field at postoperative examinations. In this study, we investigated clinicopathological features and the frequency of foreign body reaction mimicking mediastinal lymph node metastasis.

Methods:  Patients who underwent surgery for lung cancer between January 2016 and August 2021 and who were subsequently evaluated for mediastinal recurrence with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) were included. Patients were grouped according to the results of EBUS-TBNA as metastasis, foreign body, and reactive. Clinicopathological features of these patients were compared and characteristics of patients in the foreign body group were scrutinized.

Results:  EBUS-TBNA was performed on a total of 34 patients during their postoperative follow-up due to suspicion of mediastinal recurrence. EBUS-TBNA pathological workup revealed metastasis in 18 (52.9%), foreign body reaction in 10 (29.4%) and reactive lymph nodes in 6 (17.6%) patients. Mean maximum standardized uptake value (SUVMax) for metastasis group and foreign body group were 9.39 ± 4.69 and 5.48 ± 2.54, respectively (p = 0.022). Time interval between the operation and EBUS-TBNA for the metastasis group was 23.72 ± 10.48 months, while it was 14.90 ± 12.51 months in the foreign body group (p = 0.015).

Conclusion:  Foreign body reaction mimicking mediastinal lymph node metastasis is not uncommon. Iatrogenic cause of mediastinal lymphadenopathy is related to earlier presentation and lower SUVMax compared with metastatic lymphadenopathy.

Background:  Decellularized pulmonary homografts are being increasingly adopted for right ventricular outflow tract reconstruction in adult patients undergoing the Ross procedure. Few reports presented Matrix PplusN xenograft (Matrix) in a negative light. The objective of this study was to compare our midterm outcomes of Matrix xenograft versus standard cryopreserved pulmonary homograft (CPHG).

Methods:  Eighteen patients received Matrix xenograft between January 2012 and June 2016, whereas 66 patients received CPHG. Using nonparametric statistical tests and survival analysis, we compared midterm echocardiographic and clinical outcomes between the groups.

Results:  Except for significant age difference (the Matrix group was significantly older with 57 ± 8 years than the CPHG group, 48 ± 9 years, p = 0.02), the groups were similar in all other baseline characteristics. There were no significant differences in cardiopulmonary bypass times (208.3 ± 32.1 vs. 202.8 ± 34.8) or in cross-clamp times (174 ± 33.9 vs. 184.4 ± 31.1) for Matrix and CPHG, respectively. The Matrix group had significantly inferior freedom from reintervention than the CPHG group with 77.8 versus 98.5% (p = 0.02). Freedom from pulmonary valve regurgitation ≥ 2 was not significantly different between the groups with 82.4 versus 90.5% for Matrix versus CPHG, respectively. After median follow-up of 4.9 years, Matrix xenograft developed significantly higher peak pressure gradients compared with CPHG (20.4 ± 15.5 vs. 12.2 ± 9.0 mm Hg; p = 0.04).

Conclusion:  After 5 years of clinical and echocardiographic follow-up, the decellularized Matrix xenograft had inferior freedom from reintervention compared with the standard CPHG. Closer follow-up is necessary to avoid progression of valve failure into right ventricular deterioration.

Objective:  The aim of this study was to explore the effect of different organ metastasis on the prognosis of non-small cell lung cancer (NSCLC).

Methods:  Patients with distant metastatic NSCLC were selected from Surveillance, Epidemiology, and End Results database during 2016 to 2019. The incidence of different organ metastasis and their association with clinicopathological factors were explored. Overall survival (OS) and lung cancer-specific survival (LCSS) for metastatic NSCLC were calculated, and multivariate Cox regression analysis was performed with a nomogram for OS being constructed based on Cox regression.

Results:  Total 26,210 patients with distant metastatic NSCLC were included in this study. Around 48.9% of the metastatic NSCLC were multiple-organ metastasis and bone was the most commonly involved organ (44.4%). For patients with single-organ metastasis, the prognosis for lung or distant lymph nodes (LNs) metastasis was better than others (with median OS of 15 and 16 months for lung and distant LNs metastasis, respectively), and liver metastasis resulted in the worst prognosis with median OS of 8 months. A nomogram was constructed to visualize Cox regression model, along with the receiver operating characteristic (ROC) curve demonstrated good discrimination for the predictive model with 1- and 2-year area under the curve of ROC of 0.687 and 0.702, respectively.

Conclusion:  The prognosis of NSCLC patients with distant metastasis was poor. Liver metastasis results in the worst prognosis among the single-organ metastasis. The nomogram developed based on the Cox regression model has provided a useful tool to estimate the probability of OS of the metastatic NSCLC.

Background:  Carinal sleeve resection with pneumonectomy is one of the rarest procedures in thoracic surgery, but for locally advanced central lung cancer with infiltration of the carina, it is an option to achieve complete resection. Additionally, it might be the method of choice for patients with stump insufficiency after pneumonectomy or in the cases with anastomosis dehiscence after sleeve lobectomy. The aim of this study was to evaluate the morbidity and long-term survival of patients with non-small-cell lung cancer (NSCLC) who underwent sleeve pneumonectomy, either for curative intent or as an option to treat postoperative complications.

Methods:  All consecutive patients with NSCLC who underwent carinal sleeve pneumonectomy for the aforementioned indications in our department between December 2021 and September 2003 were included in this study. An analysis of demographic characteristics, perioperative variables, and long-term survival was carried out. Data were evaluated retrospectively.

Results:  Fifty patients underwent pneumonectomy with carina sleeve resection. Thirty-one cases for curative treatment of NSCLC (primary sleeve pneumonectomy [pSP]) and 19 patients were treated because of postpneumonectomy bronchial stump insufficiency or bronchial anastomosis dehiscence (secondary sleeve pneumonectomy [sSP]). Complications occurred in 30 patients (60%) and the 90-day mortality was 18% (n = 9). Patients with pSP had an estimated overall survival of 39.6 months, compared to estimated overall survival for patients after sSP of 24.5 months (p = 0.01). The N status did not appear to affect outcomes.

Conclusion:  Carinal sleeve resection with pneumonectomy is a feasible procedure with limited morbidity and mortality. This procedure is a reasonable therapeutic option for patients with locally advanced central NSCLC after mandatory patient selection.

Background:  Computational fluid dynamics (CFD) simulations model blood flow in aortic pathologies. The aim of our study was to understand the local hemodynamic environment at the site of rupture in distal stent graft-induced new entry (dSINE) after frozen elephant trunk with a clinically time efficient steady-flow simulation versus transient simulations.

Methods:  Steady-state simulations were performed for dSINE, prior and after its development and prior to aortic rupture. To account for potential turbulences due geometric changes at the dSINE location, Reynolds-averaged Navier-Stokes equations with the realizable k-ε model for turbulences were applied. Transient simulations were performed for comparison. Hemodynamic parameters were assessed at various locations of the aorta.

Results:  Post-dSINE, jet-like flow due to luminal narrowing was observed which increased prior to rupture and resulted in focal neighbored regions of high and low wall shear stress (WSS). Prior to rupture, aortic diameter at the rupture site increased lowering WSS at the entire aortic circumference. Concurrently, WSS and turbulence increased locally above the entry tear at the inner aortic curvature. Turbulent kinetic energy and WSS elevation in the downstream aorta demonstrated enhanced stress on the native aorta. Results of steady-state simulations were in good qualitative agreement with transient simulations.

Conclusion:  Steady-flow CFD simulations feasible at clinical time scales prior to aortic rupture reveal a hostile hemodynamic environment at the dSINE rupture site in agreement with lengthy transient simulations. Consequently, our developed approach may be of value in treatment planning where a fast assessment of the local hemodynamic environment is essential.

Background:  Thoracogastric airway fistula (TGAF) is a fatal complication after esophagectomy. Without active treatment, patients may die of intractable pneumonia, sepsis, massive hemoptysis, or respiratory failure. We determined the clinical value of the two-tube method that involves the precise interventional placement of the nasojejunal tube (NJT) and nasogastric tube (NGT) for TGAF.

Methods:  Clinical data of patients with TGAF who had undergone fluoroscopic interventional placement of NJT and NGT were analyzed retrospectively. The paired t-test was used to compare the index values before and after treatment. Statistical significance was set at p < 0.05.

Results:  In total, 212 patients (177 male and 35 female; mean age, 61.3 ± 7.9 years [47-73]) with TGAF who had undergone the two-tube method were included. Posttreatment chest spiral computed tomography and inflammatory indicators showed significantly improved pulmonary inflammation compared with that before treatment. The patients' general condition remained stable. Of 212 patients, 12 (5.7%) underwent surgical repair, 108 (50.9%) received placement of airway stents, and 92 (43.4%) cases only continued treatment with the two-tube method owing to patients' conditions. In total, 47.8% (44/92) patients died of secondary pulmonary infection, bleeding, and primary tumor progression, whereas 52.2% (48/92) patients survived with both tubes.

Conclusion:  The two-tube method, which involves the precise interventional placement of the NJT and NGT, is simple, safe, and effective for treating TGAF. This method is a bridge for successive treatments or a treatment itself for patients who are unsuitable for surgical repair or stent placement.