Seminars in Thoracic and Cardiovascular Surgery最新文献

Whether through minimally invasive or conventional open techniques, thoracic surgery is often reported to be one of the most painful surgical procedures due to the incision of intercostal and respiratory muscles, rib injury or resection, and placement of surgical drains. Some of the more severe complications related to poor analgesia include prolonged intensive care unit stay, mechanical ventilation, pneumonia, and the development of chronic postoperative pain syndromes. Over the past few decades, much progress has been made in recognizing the importance of multimodal analgesic techniques. These may include a variety of regional anesthetic techniques such as epidural anesthesia, fascial plane blocks, and intrapleural catheters, as well as the utilization of opioid and opioid-sparing oral regimens. This article provides an up-to-date review of pain management following thoracic surgery, emphasizing multimodal techniques and enhanced recovery pathways. In our review, we included articles published between 2010 and 2022. PubMed and Google Scholar were researched using the keywords thoracic, cardiac, pain control, thoracic epidural analgesia, fascial plane blocks, multimodal analgesia, and Enhanced Recovery after Surgery in thoracic surgery. Over 100 articles were then reviewed. We excluded articles not in English and articles that were not pertinent to cardiac or thoracic surgery. Eventually, 53 articles were included in the review, composed of clinical trials, case series, and retrospective cohort studies. A variety of pain control methods employed in thoracic and cardiac surgery range from opioids and opioid-sparing medications, such as acetaminophen and gabapentin, to regional techniques, such as fascial plane blocks to epidural anesthesia. Multimodal anesthesia combining regional and opioid-sparing analgesics and their combination in enhanced recovery protocols were shown to provide adequate pain control, decrease opioid consumption and lead to shorter lengths of stay. Postoperative pain control remains one of the biggest challenges in the care of thoracic surgery patients. Analgesic plans must be individualized for each patient. Multimodal analgesia remains the gold standard; however, more studies are still warranted. Finding the optimal combination of opioid and non-opioid pain medication and local anesthetic delivered via suitable regional technique will improve the outcomes and lead to successful patient recovery.

Centers for Medicare and Medicaid Services created a 5-star quality rating system to evaluate skilled nursing facilities (SNFs). Patient discharge to lower-star quality SNFs has been shown to adversely impact surgical outcomes. Recent data has shown that over 20% of patients are discharged to an SNF after CABG, but the link between SNF quality and CABG outcomes has not been established. The purpose of this study is to evaluate the impact of SNF quality ratings on postoperative outcomes after CABG. Retrospective cohort review of Medicare patients undergoing CABG and discharged to an SNF between the years 2016-2017. Patients were categorized into 3 groups according to the star rating of the SNF with receipt of care after discharge (ie, below average, average, above average). Risk-adjusted 30-day to 1-year outcomes of mortality, readmission, and SNF length of stay were calculated and compared using multivariable logistic regression and Poisson models across SNF quality categories. Of the 73,164 Medicare patients in our sample, 15,522 (21.2%) were discharged to an SNF. Patients in below average SNFs were more likely to be younger, Black, Medicare/Medicaid dual eligible, and have more comorbidities. Compared to above average SNFs, patients discharged to below average SNFs experienced higher risk-adjusted 30-day mortality (2.1% vs 1.6%, P<0.02), readmission (21.6% vs 19.3%, P<0.01) and SNF length of stay (17.3d vs 16.5d, P<0.0001). Within 90-days, below average SNFs experienced higher risk-adjusted readmission rates (31.7% vs 30.0%, P<0.004). Outcomes at 1-year were not statistically significant. Medicare beneficiaries discharged to lower quality SNFs experienced worse postoperative outcomes after CABG. Identifying best practices at high performing SNFs, to potentially implement at low performing facilities, may improve equitable care for patients.

Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.

The first successful lung transplant in Colombia was performed on October 28, 1997 in Medellín by Alberto Villegas Hernández at the “Clínica Cardiovascular Santa María” today called the Cardio VID Clinic. Here we present both survival outcomes and characteristics of the oldest and most experienced lung transplant program in Colombia. We conducted a retrospective study of all patients taken to lung transplantation at the Cardio VID Clinic in Medellín, Colombia from October 1997 to October 2022. Patient information from our institutional database and transplant archives were retrieved and reviewed. From October 1997 to October 2022, a total of 153 patients underwent orthotopic lung transplantation at our institution in Medellín, Colombia. Mean recipient age was 48 ± 13 years, the youngest patient was 15 years old and the oldest patient was 73 years old at the time of transplant. Seventy-four (48.4%) patients were men and seventy-nine (51.6%) were women. Uncensored lung transplant survival in Medellin at 1 month, 1 year, 5 years, and 10 years were 68%, 50%, 31%, and 12%, respectively. Although health care coverage in Colombia reaches nearly 100%, socioeconomic hurdles during post-transplant care, nonreturning patients, infections, and traumatic donor deaths lead to high mortality rates. Due to these factors, establishing successful and sustainable lung transplant programs in these settings is challenging.

Limited aortic root repair for acute type A dissection is associated with greater risk of proximal reoperations compared to full aortic root replacement. Surgical outcomes for patients undergoing reoperative root replacement after previous dissection repair are unknown. This study seeks to determine outcomes for these patients to further inform the debate surrounding optimal upfront management of the aortic root in acute dissection. Retrospective record review of all patients who underwent full aortic root replacement after a previous type A dissection repair operation at a tertiary academic referral center from 2004–2020 was performed. Among 57 cases of reoperative root replacement after type A repair, 35 cases included concomitant aortic arch replacements, and 21 cases involved coronary reconstruction (unilateral or bilateral modified Cabrol grafts). There were 3 acute postoperative strokes and 4 operative mortalities (composite 30-day and in-hospital deaths, 7.0%). Mid-term outcomes were equivalent for patients who required arch replacement compared to isolated proximal repairs (81.8% vs 80.6% estimated 5-year survival, median follow-up 5.53 years. Reoperative root replacement after index type A dissection repairs, including those with concomitant aortic arch replacement and/or coronary reconstruction is achievable with acceptable outcomes at an experienced aortic center.

We aimed to investigate the prevalence and predictors of postoperative tricuspid regurgitation (TR) worsening in patients with mitral regurgitation (MR) and concomitant ≤mild TR. A total of 620 patients underwent surgery for MR from 2013 to 2017. Of these, 260 had ≤mild preoperative TR and no concomitant tricuspid valve surgery and were enrolled in this single-center retrospective study. The primary endpoint was postoperative worsening of ≥moderate TR. The primary endpoint occurred in 28 of 260 patients (11%) during the follow-up period [median: 4.1 years (interquartile range: 2.9−6.1 years)]. In the multivariable analysis, age, female sex, and left atrial volume index (LAVI) were significant predictors of the primary outcome during intermediate-term follow-up (age: hazard ratio [HR] 1.05 per 1-year increment, 95% confidence interval [CI] 1.02–1.10, P = 0.003; female sex: HR 3.53, 95% CI 1.61–7.72, P = 0.002; LAVI: HR 1.17 per 10-mL/m² increment, 95% CI 1.07−1.26, P < 0.001). The optimal LAVI cut-off value for predicting postoperative TR worsening was 79 mL/m² (area under the curve: 0.69). A high LAVI (>79 mL/m²) was significantly associated with a low rate of freedom from postoperative TR worsening compared with a low LAVI (≤79 mL/m²) (82.6% vs 93.9% at 5 years, respectively; log-rank P = 0.008). In patients with ≤mild preoperative TR and no concomitant tricuspid surgery, the rate of postoperative TR worsening was 11% during intermediate-term follow-up. LA enlargement in patients with MR and ≤mild preoperative TR was significantly associated with postoperative TR worsening.