Thoracic and Cardiovascular Surgeon最新文献

Modern cardiovascular medicine and surgery enable the treatment of complex cardiovascular disease, even in elderly and multimorbid patients, through increasingly sophisticated procedures. Nevertheless, there are situations in which surgical intervention appears medically inappropriate or is explicitly declined by the patient. Similarly, it may become necessary in the postoperative course to revise the original therapeutic goals-particularly when continued survival depends upon prolonged intensive care unit treatment, or when the anticipated quality of life, from the patient's perspective, appears inadequate. While established guidelines and position papers-most notably from the German Interdisciplinary Association for Intensive and Emergency Medicine-are already available in the field of intensive care medicine, a discipline-specific framework for cardiac surgery has been lacking thus far. This inaugural position paper issued by the German Society for Thoracic and Cardiovascular Surgery seeks to contribute to the definition of clinical and ethical standards in the context of therapeutic restraint (Section A) and to the redefinition of therapeutic goals (Section B) within our specialty. The aim is to promote a structured and multiprofessional approach that transparently integrates the core pillars of goal setting in therapy-namely, medical indication and patient autonomy-into a comprehensible decision-making framework. Achieving this objective requires close collaboration among physicians and nursing staff in cardiac surgery, cardiology, intensive care, anesthesiology, ethics consultation, and palliative care. The present recommendations are intended to serve as a foundation for patient-centered, appropriate, and transparent decision-making-always with the overarching aim of preserving the dignity and self-determination of the patients concerned.

Concomitant cryoablation is routinely performed in patients with atrial fibrillation who undergo minimally invasive atrioventricular (AV) valve surgery. While biomarker thresholds for postoperative myocardial infarction (pMI) are established in coronary artery bypass surgery, no clear thresholds exist after concomitant cryoablation in endoscopic valve surgery. This study aimed to analyze the perioperative cardiac biomarker release patterns in this patient cohort and to evaluate the applicability of SCAI-defined pMI thresholds.We retrospectively analyzed patients who underwent endoscopic AV valve surgery from 2018 to 2024, comparing those with cryoablation (n = 165; mean age: 66.5 ± 9.5 years) to those without (n = 513; mean age: 62.4 ± 12.0 years). Perioperative creatine kinase-myocardial band (CK-MB) and troponin T (TnT) levels were measured before surgery, at 1 and 4 hours after surgery, and on postoperative day 1 (1POD). In-hospital outcomes were also assessed.Cryoablation significantly increased CK-MB (6.4 × ULN vs. 2.4 × ULN, p < 0.001) and TnT (257 × ULN vs. 80 × ULN, p < 0.001). Compared with SCAI pMI criteria (CK-MB > 10 × ULN; TnT > 70 × ULN), CK-MB remained below the threshold, while TnT exceeded it in most cases (p < 0.05). Despite these elevations, clinical pMI was rare (two cases vs. three cases). In-hospital mortality did not differ significantly between the groups (1.2% vs. 1.6%; p = 1.000).Cryoablation during minimally invasive AV valve surgery markedly increases postoperative cardiac biomarkers without higher clinical pMI rates. Procedure-specific biomarker thresholds and validation of SCAI criteria are essential for accurate diagnosis and patient management.

Objective: Postoperative atrial fibrillation (POAF) is a frequent complication after coronary artery bypass grafting (CABG) and is linked to increased short- and long-term stroke risk. This study evaluated the prognostic value of the left atrial diameter index (LADI) for predicting cerebrovascular events (CVE) in patients undergoing isolated CABG who developed POAF, had no prior atrial fibrillation (AF), and were discharged in sinus rhythm.

Materials and methods: Among 2094 patients undergoing isolated CABG between June 2015 and June 2022, 392 consecutive patients with POAF and discharge in sinus rhythm met inclusion criteria. LADI was calculated preoperatively, and an optimal cutoff (21.2 mm/m²) was determined via receiver operating characteristic (ROC) curve and Youden index. Patients were classified as low (≤21.2 mm/m²) or high (>21.2 mm/m²) LADI. The association between LADI and CVE was assessed over a mean follow-up of 42.4±20.0 months using Cox proportional hazards modeling.

Results: Thirty patients (7.7%) experienced a CVE, including 8 in-hospital cases (2.0%). CVE incidence was higher in the high LADI group compared to the low LADI group (19.8% vs. 2.8%). Multivariable analysis identified older age, hypertension, congestive heart failure, and high LADI as independent CVE predictors. Kaplan-Meier analysis confirmed significantly higher CVE rates in the high LADI group (log-rank p<0.001).

Conclusion: In patients developing POAF after isolated CABG, LADI is a simple, easily obtainable parameter that independently predicts long-term CVE risk and may aid in postoperative risk stratification.

This study investigated factors leading to treatment failure after negative pressure wound therapy (NPWT) in poststernotomy mediastinitis (PSM) patients.A single-center retrospective case-control study in 198 cardiac surgery patients with PSM and consecutive NPWT were retrospectively divided into two groups. Group I consisted of patients whose NPWT was successful (n = 117/198; 59.1%), while in Group II treatment, failure occurred (n = 81/198; 40.9%). The primary endpoint was treatment failure, defined as recurrence of wound infection requiring surgical treatment within 30 days after secondary wound closure.Body mass index (BMI) >30 kg/m² (p = 0.04; odds ratio [OR] 1.07), diabetes mellitus (DM; p = 0.03; OR 1.94), and the number of sponge changes (p = 0.01; OR 1.57) showed an association with the occurrence of NPWT failure. During the study period, 10/198 (19.8%) patients died after secondary wound healing. In group I, 1/117 (0.9%) patient died versus group II with 9/81 (12.7%) patients. About 70% patients died from septic multiple organ failure.This study confirms that variables associated with treatment failure after NPWT in PSM are BMI >30 kg/m², diabetes mellitus (DM), and the "number of sponge changes," respectively. However, this does not mean that sponge changes increase the risk; rather, sponge changes are associated with more resistant germs, incomplete wound healing, and more aggressive infection. This implies that management should be in the hands of cardiac surgeons with extensive experience in septic surgery and at centers with expertise in order to minimize the duration of NPWT and thus the number of sponge changes.

Prognostic heterogeneity may exist among T3 nonsmall cell lung cancers depending on specific T3 descriptors. Our study aimed to evaluate the survival differences among T3 subgroups in patients with resected lung cancer.This retrospective cohort study included 381 patients with pathologically confirmed (p)T3N0/1 nonsmall cell lung cancer. Patients with mediastinal lymph node metastases or superior sulcus tumors were excluded. Patients were classified into three subgroups; the T3-ordinary group (only tumor diameter >5 cm but ≤7 cm, or only an additional tumor nodule in the same lobe as the primary tumor, n = 246), the T3-invasion group (the primary tumor directly invades any of the structures; only the phernic nerve, pericardium, parietal pleura or the chest wall, n = 57), and the T3-multiple group (the tumor had at least two T3 descriptors, n = 78).The 5-year overall survival rate was 52% (median survival time: 63 months; 95% CI: 53-72 months). A significant difference was observed between the three groups in terms of median survival time (T3-ordinary, 70 months; T3-invasion, 58 months; T3-multiple, 43 months; chi-square = 5.86, p = 0.04-log rank). Moreover, the 5-year survival rate was significantly higher in the T3 single group than in the T3 multiple group (54.5% vs. 40.4%, p = 0.03). Multivariate analysis showed that lymph node status (p = 0.007), adjuvant treatment (p < 0.001), major surgical complications (p < 0.001), and T3-subgroups (p = 0.02) were independent prognostic factors.Patients with two or more pT3 descriptors or tumors exhibiting invasion have the worst survival rates. Stage migration can be discussed in these patients.

The 2017 and 2021 ESC/EACTS guidelines for the management of valvular heart disease recommend transcatheter aortic valve implantation (TAVI) as a treatment option for severe symptomatic aortic valve stenosis (AS) in patients ≥75 years of age. However, surgical aortic valve replacement (SAVR) remains a viable option for elderly patients, particularly in specific anatomical or clinical subsets. The objective of this study was to analyze indications for SAVR and postoperative outcomes in patients ≥75 years of age.Heart team protocols were reviewed to determine indications for SAVR. The adjudication of acute procedural and early clinical outcomes was conducted in accordance with the standardized VARC-3 definitions. Furthermore, cardiovascular mortality and rate of aortic valve re-intervention were assessed at latest follow-up with a median duration of 5.5 years (1.9-7.1 years).A total of 43 patients ≥75 years of age (51% male) underwent isolated SAVR at our center between 2017 and 2022. STS/EuroSCORE II was 1.7 ± 0.6%/1.7 ± 0.4%. The age distribution of patients was as follows: 75 to 76 years in 32.5% (14/43), 77 to 79 years in 46.5% (20/43), and 80 to 83 years in 21% (9/43) of patients. Indications for SAVR included low operative risk according to STS (1.6 ± 0.3%) and EuroSCORE II (1.4 ± 0.3%) in 51.2% (22/43), unicuspid/bicuspid aortic valve in 21% (9/43), patient preference in 13.9% (6/43), large aortic annulus in 9.3% (4/43), and massive calcification of the left ventricular outflow tract in 4.6% (2/43) of patients. Mean aortic cross clamp and cardiopulmonary bypass times were 67.1 ± 18.2 minutes and 98.6 ± 25.1 minutes. All-cause 30-day mortality was 0% (0/43). Technical success, device success, and early safety were 100% (43/43), 100% (43/43), and 81.4% (35/43). Bleeding complications and the need for permanent pacemaker implantation (PPM) were observed in 9.3% (4/43) and 4.6% (2/43) of patients. Mean ICU and hospital stay were 2.9 ± 2.1 days and 12.5 ± 3.6 days. Post-procedural echocardiography demonstrated absence of paravalvular leakage (PVL) in all but one patient, who exhibited moderate PVL. The mean transvalvular pressure gradient was 11.4 ± 4.5 mmHg. Latest follow-up was at median 5.5 years (1.9-7.1 years). Aortic valve re-intervention at follow-up was 2.3% (1/43) and cardiovascular mortality was 4.6% (2/43).In the current era, SAVR is rarely performed in patients ≥75 years of age. Despite the highly selective nature of the patient cohort studied, the results are excellent, with a 30-day mortality of 0% and a low cardiovascular mortality at 5 years. SAVR should still be considered a valid option in elderly patients, evaluated by a heart team, which considers each patient's unique clinical, anatomic, and procedural characteristics.

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality worldwide, with Sub-Saharan Africa (SSA) facing a severe shortage of cardiac surgeons (0.12 per million people) and limited access to cardiac surgical care. This study explores the career aspirations of African medical students and examines the factors influencing their interest in pursuing various career paths and cardiac surgery in particular.A cross-sectional study was conducted among 807 medical students from various African medical schools. Data were collected using a validated online questionnaire available in English, French, and Arabic. Sociodemographic characteristics, career aspirations, specialty preferences, and factors influencing career choices were analyzed using descriptive and bivariate statistical methods.The mean age of participants was 22.79 ± 2.99 years, with a nearly equal gender distribution (51.2% male, 48.8% female). Surgery was the most preferred specialty (34.3%), cardiac surgery was chosen by 11.8% of participants, and 0.5% chose cardiothoracic surgery. The inclusion of cardiac surgery in the curriculum (p = 0.046) and exposure to cardiac patients (p = 0.034) positively influenced career interest. However, the presence of functional cardiac surgery units in teaching hospitals was negatively associated with pursuing the specialty (p = 0.032). Additionally, hospital-based exposure to cardiac surgery significantly reduced interest in cardiac surgery (p < 0.001) as specialty choice. A majority (71.4%) intended to pursue postgraduate studies abroad, citing limited local opportunities.The level of interest in cardiac surgery among African medical students highlights the need for targeted interventions, including curriculum reforms, improved training environments, and structured mentorship programs to translate this interest into cardiac surgical workforce. Strengthening local postgraduate training capacity and addressing systemic barriers are crucial steps in building a sustainable cardiac surgery workforce in Africa, ultimately helping to reduce the burden of cardiovascular diseases across the continent.

Postoperative atrial fibrillation (POAF) is a frequent entity after cardiac surgery. However, its potential relationship with adverse outcomes and permanent arrhythmias remains uncertain. We sought to assess the relationship between the occurrence of atrial fibrillation (AF) in the postoperative period and its long-term recurrence.Patients who underwent aortic valve replacement (AVR) with a biological prosthesis between 2005 and 2023 were analyzed at our center. The incidence of atrial fibrillation in the postoperative period and the factors associated with its occurrence, as well as its long-term recurrence and related risk factors, were analyzed.The incidence of POAF was 22%. Postoperative renal insufficiency (p < 0.001) and chronic obstructive pulmonary disease (COPD) (p = 0.047) were identified as risk factors. During long-term clinical follow-up (mean 6.5 ± 4.5 years), 20.4% of patients without any previous arrhythmia episodes developed AF, whereas the incidence was 40.4% in those with atrial fibrillation in the postoperative period (Hazard Ratio [HR] = 2.18 [1.33-3.56]; p = 0.002). AF during follow-up was independently associated with age (HR = 1.05), COPD (HR = 3.22), and POAF (HR = 1.9). In addition, there was an apparent association between permanent AF during follow-up and long-term mortality, which approached statistical significance (HR = 1.4 [95% CI: 0.9-1.8]; p = 0.06).POAF is a frequent complication following AVR and is significantly associated with an increased risk of developing permanent AF during long-term follow-up. Multivariate analysis identified renal insufficiency and COPD as independent predictors of POAF, while age and COPD were independently associated with long-term AF. Additionally, there was a trend toward an association between permanent AF and increased long-term mortality.