Seminars in Thoracic and Cardiovascular Surgery最新文献

ECLS-SHOCK is the largest randomized control trial on Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in Acute Myocardial Infarction-related Cardiogenic Shock (AMI-CS). Unfortunately, ECLS-SHOCK failed to demonstrate a reduction of mortality in AMI-CS with VA-ECMO. Interpretation of these findings must account for frequent crossover to VA-ECMO or other temporary mechanical circulatory support (tMCS) devices in the control group, as well as the exceptionally high severity of illness among participants. We detail here point by point what could explain the outcomes and the unanswered questions. In the light of these results, a liberal use of VA-ECMO might be avoided. Further trials are needed to refine patient selection criteria and determine the optimal timing ("sweet-spot") for VA-ECMO implementation. Current practice and future guidelines will have to take in count ECLS-SHOCK results.

Artificial pleural effusion (APL) has been described for image guided biopsy of the dome of the liver.¹ This paper demonstrates APL is also useful for percutaneous, ultrasound-guided needle access to the pericardium. Approximately 35 patients of 200 that underwent ultrasound-guided pericardiocentesis (UGP) by the author had incidental left pleural effusions (PE). In these cases the pericardium was approached through the pleural fluid under direct ultrasound guidance. The space created by the pleural fluid is analogous to the operative field that pneumothorax affords video-assisted thorascopic surgery (VATS). Five patients without left pleural effusion had no appropriate percutaneous entry site, 500 ml to 1000 ml sterile saline was instilled to the left pleura with the intention of improving visualization and needle access to the pericardium. Most effusions were completely drained. No anesthetic or bleeding complications by the author in over 200 total UGP cases. Left pleural effusion can provide a convenient acoustic window for ultrasound guided pericardiocentesis. Saline can be instilled to the pleura to create and artificial pleural effusion. Posterior pericardial effusions are amenable to this technique. Improved visualization may reduce complications and improve patient safety.

Lack of consensus on the treatment of tricuspid regurgitation (TR) has limited operative management for decades. However, emerging evidence indicates that intervening on moderate tricuspid regurgitation during concomitant cardiac surgery can be beneficial with appropriate patient selection. Furthermore, advances in transcatheter therapies have changed the landscape of managing tricuspid disease.

Quality improvement and enhanced recovery initiatives for coronarybypass surgery have reduced complications, shortened hospital stay and recovery times, and improved patient outcomes. Beyond the Society of Thoracic Surgery's (STS) quality metrics, many other operative measures, such as completeness of revascularization, and patient care measures add quality and value for patients undergoing coronary artery bypass surgery; and Enhanced Recovery after Surgery (ERAS) protocols have improved patient experience and recovery, leading to better outcomes and significant healthcare savings.

Beating-heart coronary artery bypass grafting (CABG) in patients with left ventricular (LV) dysfunction can provide the best of all words by limiting myocardial injury purported by cardioplegic arrest. Complete revascularization is possible and graft numbers are not different when compared to arrested heart CABG. Furthermore, beating-heart CABG more often reduces the need for intraoperative and postoperative mechanical support reducing the complications and costs associated with these devices.

Proximal control of the thoracic aorta during the open repair of thoracoabdominal aorta can be challenging. Various techniques have been developed to address these challenges, including the use of deep hypothermic circulatory arrest and staged procedures, such as the conventional as well as frozen elephant trunk procedures. This paper is a brief review of the challenges and rationale behind some approaches.

Subspecialization in surgery is increasingly common and for great reasons. Over the past 20 years, there has been evidence in support of the link between subspecialization in the disciplines of orthopedic surgery, general, thoracic surgery, neurosurgery, and in interventional cardiology and better patient outcomes and technical advances in their respective fields. In addition, studies suggest that increased hospital and surgeon volume throughout surgery may lead to improved surgical outcomes. The degree of specialization has been shown to reduce operative mortality in a variety of procedures and highlights that the level of sophistication and fund of knowledge required within each area is so great that no one surgeon can "do it all" and do it well. Cardiac surgery has become more subspecialized; however, many still view coronary artery surgery as a generalist procedure. There is debate as to the relative contribution of hospital volume, surgeon volume, or degree of specialization on perioperative mortality following isolated coronary artery bypass grafting. In this paper, we will discuss the current data supporting the need for specialization in coronary surgery and present arguments in favor of further specialization in this field.