Seminars in Thoracic and Cardiovascular Surgery最新文献

Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.

To identify risk factors associated with mortality and reintervention on primary arterial switch operation for Taussig-Bing anomaly in 225 cases over a 16-year period. From 2002 to 2017, 225 children with Taussig-Bing anomaly received a primary arterial switch operation at the Shanghai Children's Medical Center. Perioperative data and follow-up results were collected. Univariate and multivariable analysis was used to explore risk factors associated with early mortality. The competing risk analysis was used to identify risk factors related to reintervention. Early mortality was 12.9% (29/225) with a satisfactory long-term survival rate (10-year survival rate 85.0%). The median age at repair was 77 days (interquartile range, IQR, 48–139). The median duration of follow-up was 4.6 (range 0.1–18.3) years. 87 children (38.7%) received concomitant aortic arch repair. Prolonged cardiopulmonary bypass time (a-OR 1.18, 95% confidence interval [CI], 1.09–1.28, p < 0.001) is found to be an independent risk factor for early death. Larger weight at repair tends to be a protective factor (a-OR 0.66, 95% CI, 0.425–1.02, p = 0.060) and intramural coronary artery (a-OR 4.81, 95% CI, 0.927–24.9, p = 0.062) tends to be a risk factor for early mortality. The cumulative incidence rate of overall reintervention was 18.9% (95% CI, 10.3%–27.4%) at 5 years and 32.3% (95% CI, 17,0%–47.6%) at 10 years. No independent risk factors were identified for long-term overall reintervention. Prolonged aortic-cross clamp time was an independent risk factor for long-term right-sided reintervention (adjusted hazard ratio [a-HR] 1.12, 95% CI 1.005–1.25, p = 0.041). Neo-aortic regurgitation was a concern with an incidence rate of moderate or greater neo-AR of 16.1 % (95% CI 7.6%–24.7%) at 10 years. Intramural coronary artery remains a surgical challenge in primary arterial switch operation for the Taussig-Bing anomaly. Larger weight at ASO tends to be a protective factor for early death. Reintervention is frequently necessary but can be performed with satisfactory results.

Risk of aortic dissection in ascending thoracic aortic aneurysms is not sufficiently captured by size-based metrics. From a biomechanical perspective, dissection may be initiated when wall stress exceeds wall strength. Our objective was to assess the association between aneurysm peak wall stresses and 3-year all-cause mortality. Finite element analysis was performed in 273 veterans with chest computed tomography for surveillance of ascending thoracic aortic aneurysms. Three-dimensional geometries were reconstructed and models developed accounting for prestress geometries. A fiber-embedded hyperelastic material model was applied to obtain circumferential and longitudinal wall stresses under systolic pressure. Patients were followed up to 3 years following the scan to assess aneurysm repair and all-cause mortality. Fine-Gray subdistribution hazards were estimated for all-cause mortality based on age, aortic diameter, and peak wall stresses, treating aneurysm repair as a competing risk. When accounting for age, subdistribution hazard of mortality was not significantly increased by peak circumferential stresses (p = 0.30) but was significantly increased by peak longitudinal stresses (p = 0.008). Aortic diameter did not significantly increase subdistribution hazard of mortality in either model (circumferential model: p = 0.38; longitudinal model: p = 0.30). The effect of peak longitudinal stresses on subdistribution hazard of mortality was maximized at a binary threshold of 355kPa, which captured 34 of 212(16%) patients with diameter <5 cm, 11 of 36(31%) at 5.0–5.4 cm, and 11 of 25(44%) at ≥5.5 cm. Aneurysm peak longitudinal stresses stratified by age and diameter were associated with increased hazard of 3-year all-cause mortality in a veteran cohort. Risk prediction may be enhanced by considering peak longitudinal stresses.

Robot-assisted minimally invasive esophagectomy (RAMIE) has been proven to be a feasible surgical approach for esophageal squamous cell carcinoma (ESCC). This study aimed to investigate the recurrence pattern and potential risk factors after RAMIE. Consecutive patients with ESCC who received RAMIE with McKeown technique at a single Esophageal Cancer Institute from November 2015 to September 2018 were retrospectively reviewed. Patients with available data, radical resection (R0), and a minimum 2-year follow-up period were eligible for the recurrence analysis. Risk factors of recurrence were examined by logistic regression analysis. R0 resection was achieved in 95.1% of patients (310/326). Of the 298 eligible patients with a median follow-up period of 30.6 months, recurrence was recognized in 95 patients (31.9%), with 4 (1.3%) local-only, 40 (13.4%) regional-only, 44 (14.8%) hematogenous-only and 7 (2.3%) combined recurrences. Cervical lymph nodes and lungs were the most frequent sites of regional and hematogenous recurrence, respectively. The median disease-free interval until recurrence was 12.1 (range 1.7–37.6) months and 83.2% of relapses occurred within 2 years after surgery. Multivariable analysis indicated that tumor in the upper esophagus, larger tumor length and positive lymph nodes as independent risk factors for recurrence. Hematogenous recurrence is the prevailing pattern after RAMIE for ESCC. For patients with advanced disease, neoadjuvant therapy is a key factor in reducing recurrence rather than surgical approaches.

Repair of tetralogy of Fallot (TOF) can be complicated by the presence of an anomalous coronary artery (ACA) crossing the right ventricular outflow tract (RVOT). This study sought to evaluate the late outcomes of a policy of transatrial-transpulmonary repair for this condition. The transatrial-transpulmonary approach was used in 864 consecutive TOF repairs between 1993 and 2018 at a single institution, of which 55 (6%) patients had an ACA. Nineteen (35%,19/55) patients underwent prior palliation. Late survival and freedom from reoperations were compared with the general cohort of 809 patients who underwent complete repair during the same period. Early mortality was 2% (1/55). Median follow-up was 15.6 years. Late mortality was 6% (3/54). Absence of a preoperative diagnosis of ACA was not a risk factor for worse outcomes in terms of late re-interventions, acute coronary syndrome, residual RVOT gradient, and late mortality. Survival was 91% (95% confidence interval [CI]: 77–96%) at 20 years and was comparable to the general TOF cohort (95%, 95% CI: 90–98%, P = 0.12). Actuarial freedom from any re-intervention was 46% (95% CI: 27–62%) at 20 years, which was also comparable to the general cohort (31%, 95% CI: 20–42%, P = 0.19). The presence of an ACA does not appear to affect late survival or re-intervention rates in patients undergoing transatrial-transpulmonary repair of TOF.