Seminars in Thoracic and Cardiovascular Surgery最新文献

Transcatheter Aortic Valve Replacement (TAVR) continues to grow in popularity and has become the preferred mechanism for the treatment of aortic stenosis in most patients. Despite significant improvements in the safety of TAVR, complications remain inevitable. Aortic dissection, although rare, is a feared complication following TAVR. Aortic dissection after TAVR has been reported to occur in both the ascending and descending thoracic aorta and may occur acutely during valve placement or in a delayed fashion. Bicuspid aortic valve and ascending aortic aneurysm may increase the risk for Type A dissection following TAVR. Given the rarity of aortic dissection in TAVR, a high index of suspicion must be maintained to provide prompt diagnosis and management. Open surgical repair is the preferred treatment modality for type A aortic dissection, however endovascular management and conservative medical therapy can be utilized in select patients and are more commonly employed for type B dissection.

The Clinical Practice Standards Committee of the American Association for Thoracic Surgery assembled an expert panel and conducted a systematic review of the literature detailing studies directly comparing treatment options for high-risk patients with stage I non-small cell lung cancer (NSCLC). A systematic search was performed to identify publications comparing outcomes following image-guided thermal ablation (IGTA), stereotactic ablative radiotherapy (SABR), and sublobar resection-the main treatment options applicable to high-risk patients with stage I NSCLC. There were no publications detailing completed randomized controlled trials comparing these treatment options. Several retrospective studies with comparisons were identified, some of which used large, population-based registries. The findings in 18 of these studies are summarized in this Expert Review article. Registry studies comparing IGTA with SABR in propensity-score matched patients with stage I NSCLC found no difference in overall survival. The use of thermal ablation was less frequent and had wider variation depending on geographic region as compared with SABR, however. Studies yielding high-quality data comparing SABR with sublobar resection have been limited. When comparing sublobar resection with IGTA, sublobar resection was associated with superior primary tumor control and overall survival in the retrospective cohort studies. Retrospective comparative studies are difficult to assess due to the inherent biases or treatment selection and the definitions of loco-regional control. Prospective randomized trials are needed to fully evaluate the outcomes of treatment options applicable to high-risk patients with early-stage lung cancer.

Stereotactic ablative radiotherapy (SABR) has emerged as an alternative, non-surgical treatment for high-risk patients with stage I non-small cell lung cancer (NSCLC) with increased use over time. The American Association for Thoracic Surgery (AATS) Clinical Practice Standards Committee (CPSC) assembled an expert panel and conducted a systematic review of the literature evaluating the results of SABR, which is also referred to as stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS), prior to developing treatment recommendations for high-risk patients with stage I NSCLC based on expert consensus. Publications detailing the findings of 16 prospective studies of SABR and 14 retrospective studies of SABR for the management of early-stage lung cancer in 54 697 patients were identified by systematic review of the literature with further review by members of our expert panel. Medical inoperability (93-95%) was the primary reason for utilizing SABR. The median rate of histologically confirmed cancer in treated patients was 67% (range 57-86%). In retrospective studies and prospective studies, the most common dosing regimens were 48-54 Gy in 3-5 fractions and 44-66 Gy in 3-5 fractions respectively. The median follow-up after SABR was 30 months (range 15-50). The complications, oncological results and quality of life after SABR in high-risk patients with early-stage NSCLC are summarized in this Expert Review article. Further prospective randomized trials are needed and are currently underway to compare outcomes after SABR with outcomes after sublobar resection to fully evaluate treatment options applicable this high-risk group of patients.

Sublobar resection offers a parenchymal-sparing surgical alternative to lobectomy and includes wedge resection and segmentectomy. Sublobar resection has been historically utilized in high-risk patients with compromised lung function; however, the technique is becoming more prevalent for normal-risk patients with peripheral lung tumors < 2 cm. In this article, we summarize the technique of sublobar resection, the importance of surgical margins and lymph node sampling, patient selection, perioperative complications, outcomes, and the impact of sublobar resection on the quality of life. There is limited data on short-term and long-term outcomes after sublobar resection for stage I NSCLC in high-risk patients. Results from randomized clinical trials (RCTs) of sublobar resection have been variable. We have summarized the results of the ACOSOG Z4032 RCT, which compared outcomes in high-risk patients who underwent sublobar resection alone versus sublobar resection with brachytherapy for stage I NSCLC. In addition, we have summarized recent findings of the CALGB/Alliance 140503 RCT comparing sublobar resection and lobectomy, which suggested that disease-free survival after sublobar resection in patients with small (< 2 cm) peripheral NSCLC was non-inferior to lobectomy, and another RCT (JCOG 0802) of segmentectomy vs. lobectomy for small peripheral clinical stage IA NSCLC, where segmentectomy was associated with better overall survival despite a higher local recurrence rate. Sublobar resection is primarily performed with minimally invasive approaches, including robotic assisted and video-assisted thoracoscopic techniques. From an oncologic perspective, obtaining adequate surgical margins and performing an adequate lymph node evaluation are critical for good outcomes after sublobar resection.

The robotic platform may provide advantages over sternotomy including improved visualization and greater dexterity. With emerging evidence increasingly supporting the importance of concomitantly addressing tricuspid regurgitation and atrial fibrillation, robotic surgeons should be encouraged to perform appropriate concomitant procedures where indicated.

Refractory angina is a debilitating disease with limited therapeutic options that is primarily caused by microvascular dysfunction and desertification. Towards addressing this unmet need, microvascular revascularization therapy has progressively evolved from the lizard heart inspired transmyocardial revascularization to precisely inducing vascular endothelial growth factor with gene therapy. Gene therapy with adenoviral vehicles or naked modified ribonucleic acid is safe and shows early signs of clinical promise but has not yet been proven effective due to gaps in optimization.

Objective: A significant proportion of patients with stage I non-small cell lung cancer (NSCLC) are considered at high risk for complications or mortality after lobectomy. The American Association for Thoracic Surgery (AATS) previously published important considerations in determining which patients are considered high risk. The current objective was to evaluate treatment options and important factors to consider during treatment selection for these high-risk patients.

Methods: The AATS Clinical Practice Standards Committee assembled an expert panel to review treatment options for high-risk patients with stage I NSCLC. After a systematic search of the literature identification of lung-nodule-related factors to consider in treatment selection, the panel developed expert consensus statements and vignettes using a modified Delphi method. A 75% consensus was required for approval.

Results: The expert panel identified sublobar resection, image-guided thermal ablation (IGTA), and stereotactic ablative radiotherapy (SABR), which is also known as stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS), as modalities applicable in the treatment of high-risk patients with stage I NSCLC. Fourteen statements and 5 vignettes illustrating clinical scenarios were formulated, revised, and ultimately approved.

Conclusions: The choice of which modality (sublobar resection, SABR, or IGTA) is optimal in high-risk patients with stage I NSCLC is complex, but a surgical approach is generally favored when deemed safe. SABR and IGTA are reasonable options in select patients, with SABR being the likely next choice in nonsurgical patients. If possible, obtaining a biopsy is very important prior non-surgical treatment. A multi-disciplinary review of patient and tumor characteristics is essential for achieving an optimal decision. The clinical treatment decision should also take patient perspectives, preferences, and quality of life into consideration.

Objective: The American Association for Thoracic Surgery (AATS) Clinical Practice Standards Committee (CPSC) previously published important considerations in determining who is at high risk for complications or mortality after lobectomy. Sublobar resection, stereotactic ablative radiotherapy, or image-guided thermal ablation is typically considered when the risks associated with lobectomy are high. The current objective was to evaluate important lung-nodule-related factors to consider during treatment selection for high-risk patients with stage I non-small cell lung cancer (NSCLC).

Methods: The AATS CPSC assembled an expert panel. The expert panel generated an a priori list of lung-nodule-related factors to consider in treatment selection and graded the relative importance of each factor on a scale of 1-10 in an anonymous survey after systematic review of the literature.

Results: The expert panel survey identified several lung-nodule-related factors to consider in treatment selection. The panel ranked tumor location (peripheral vs central, mean score 8.4), tumor size (mean score 8.1), proximity to bronchovascular and critical structures (mean score 7.8), and the presence of interstitial lung disease/idiopathic pulmonary fibrosis (mean score 7.8) as the most important factors to consider.

Conclusions: This article summarizes the lung-nodule-related factors to consider when deciding between sublobar resection, stereotactic ablative radiotherapy, and image-guided thermal ablation during treatment selection for high-risk patients with stage I NSCLC. When possible, obtaining a biopsy is very important prior to non-surgical treatments. The choice of which modality is optimal in high-risk patients with stage I NSCLC is complex. A multi-disciplinary review of patient and tumor characteristics is essential for achieving an optimal decision.