Journal of Thoracic and Cardiovascular Surgery最新文献

Objective(s): To evaluate the incidence, mechanisms, and timing of recurrent mitral regurgitation (MR) requiring reoperation after degenerative mitral valve repair (MVr), and to assess its impact on long-term survival and cardiovascular readmissions in a large single-center cohort with over three decades of follow-up.

Methods: All MVr procedures performed between January 1991, and May 2024 were reviewed (n = 2,383). After excluding patients with non-myxomatous etiologies, prior mitral surgery, non-repair procedures, and associated major interventions, 1,222 patients with isolated degenerative MR comprised the final cohort. Outcomes were obtained from a provincial administrative database. The primary endpoint was reoperation for recurrent MR; secondary endpoints included long-term survival and cardiovascular readmissions. Multivariable analyses used Cox-based approaches and generalized linear models.

Results: Reoperation occurred in 82 patients (6.7%). Early failures (<1 year) represented 35.4% and were predominantly technical (62% of early failures), whereas late failures (≥1 year) accounted for 64.6% and were mainly driven by disease progression (35.9% of late failures) or fibrosis (32.1%). Freedom from reoperation was 97.6% at 1 year, 94.9% at 5 years, and 88.2% at 20 years. Residual MR ≥2+ at discharge was the strongest predictor of reoperation (hazard ratio [HR] 7.53, 95% confidence interval [CI] 4.76-11.90; p < 0.0001) and of early dysfunction (HR 10.90; p < 0.0001). Long-term survival did not differ between reoperated and non-reoperated patients (HR 1.18, 95% CI 0.75-1.86; p = 0.49). Cardiovascular readmissions were significantly more frequent before reoperation, with an annualized rate of 0.17 events per patient-year compared with 0.07 after reoperation; this reduction was highly significant (p < 0.0001 by Poisson regression).

Conclusions: In a highly specialized mitral repair program, reoperation for recurrent MR is uncommon and does not negatively affect long-term survival. Residual MR at discharge is the principal determinant of repair failure, and timely reoperation restores clinical stability and substantially reduces cardiovascular morbidity.

Background: Cardiofibroblasts are closely involved in the process of ischemia and inflammation. Nevertheless, the role of cardiofibroblasts remains unknown in the heart transplantation.

Methods: Syngeneic and allogeneic heterotopic cardiac transplantation was performed using C57BL/6 or BALB/c donors for BALB/c recipients through different treatments. Some mice were utilized to observe the survival of the cardiac grafts. qPCR, western blotting, flow cytometry, and immunofluorescence staining were used to identify the fibroblast function in heart graft.

Results: Our study revealed that cardiac fibroblasts were activated and transformed into myofibroblasts. In the myofibroblasts of heart allografts, the expression levels of the autophagy-related proteins 5 (ATG5), ATG7, and microtubule-associated protein light chain 3-II (LC3-II) were increased. Conditional deletion of ATG5 in donor myofibroblasts prolonged heart graft survival, reduced infiltration of inflammatory cytokines (including interleukin-6, interleukin-1β, tumor necrosis factor-α, and interleukin-18), and inhibited CD8⁺ T cell proliferation. In the MR-1-induced chronic cardiac transplantation model, these conditional knockout grafts also exhibited prolonged survival and reduced fibrosis.

Conclusion: Significant prolongation of cardiac allograft survival might be achieved by suppressing the activity of cardiofibroblasts, which could be effectively regulated by targeting fibroblastic ATG5, a critical component of autophagy.

Objective: This window of opportunity phase 1/1b clinical trial evaluated the role of neoadjuvant injection of the viral mimic poly-ICLC in patients with pleural mesothelioma undergoing curative-intent surgical resection.

Methods: Patients with documented pleural mesothelioma who were deemed resectable underwent intratumoral injection of poly-ICLC 2-4 weeks prior to planned curative-intent surgery. Safety and toxicity were the primary endpoints and secondary endpoints were postoperative complications, mortality, and overall survival, with patients censored at the date of last follow-up if not known to be deceased.

Results: From 2020 to 2024, 19 patients underwent treatment followed by pleurectomy/decortication a median of 19 days (range 14-192) later. Poly-ICLC was well tolerated with drug-related Grade I toxicities occurring in 7 (37%) patients. All patients were resectable and the diaphragm and pericardium preserved. Median length of stay was 7 days (range 3-19), post-operative complications were minor, except one cardiac arrest due to complete heart block and there were no deaths within 90 days of surgery. Median overall survival was 19.6 months from injection (95% CI: 14.7-NR) and 19.1 (95% CI: 13.4-NR) from surgery. One patient whose surgery was delayed and underwent systemic chemotherapy following injection was found to have complete response to poly-ICLC and systemic treatment.

Conclusions: This prospective clinical trial is the first to demonstrate the safety of intratumoral injection of poly-ICLC with excellent surgical results and favorable survival, with one patient experiencing dramatic response to injection and chemotherapy. Use of poly-ICLC as an immunostimulant with combinatorial strategies offers hope for treating this challenging disease.

Objective: To analyze the in-hospital outcomes of patients undergoing re-operative aortic arch repair and identify risk factors for mortality and morbidity using data from a multicenter, national registry.

Methods: We collected data on patients undergoing aortic arch repair (hemiarch or total arch replacement with or without elephant trunk/frozen elephant trunk) under circulatory arrest between 2002 and 2021, including those with acute aortic dissection. Patients with a history of previous open-heart surgery were defined as the redo cases (aortic-redo group and other-redo group). The primary outcomes were operative mortality and a modified Society of Thoracic Surgeons composite endpoint for mortality and major morbidity (MMOM). The MMOM composite endpoint was defined as: operative mortality, stroke, dialysis-dependent renal failure, deep sternal wound infection, reoperation, prolonged ventilation of >40 hours. Blood transfusion rates were also analyzed.

Results: Overall, 374 (15%) of 2481 patients were in the redo cohort. The overall operative mortality of aortic arch reoperations was 12%. Although redo patients had a significantly higher comorbidity burden, no significant difference was identified for the operative mortality among primary, aortic-redo and other-redo groups (9.3% vs. 11% vs. 14%, p = 0.132), and for the MMOM incidence (30% vs. 34% vs. 39%, p = 0.075). Additionally, transfusion requirements and ICU/hospital stays were higher in both redo groups (p < 0.001). To further analyze the redo group, all patients were divided into four groups: Primary hemi-arch group (n = 1800), primary total-arch group (n = 307), redo hemi-arch group (n = 266) and redo total-arch group (n = 108). Operative mortality was significantly higher in the redo hemi-arch group (p = 0.014). In contrast, there was no significant difference in mortality or MMOM between primary and redo total-arch groups (p > 0.05). Multivariable analyses identified older age, acute aortic dissection, and prolonged CPB time (log-transformed) as independent predictors of both operative mortality and MMOM in reoperative arch repair.

Conclusions: This study of a national registry demonstrated that selected aortic arch reoperations can be performed with acceptable safety. Older age, acute aortic dissection, and prolonged CPB time are associated with worse operative outcomes. Further studies are needed to optimize surgical techniques and perioperative care, in addition to selecting patients who would benefit most from reoperative open arch surgery.

Objective: The internal geometric annuloplasty ring is the only commercially available aortic annuloplasty ring designed to reduce and prevent annular dilatation during aortic valve repair. However, data regarding its long-term durability remain limited. We present our mid-term outcomes.

Methods: A retrospective review was conducted of all adult patients who underwent aortic valve repair using the internal geometric annuloplasty ring between January 2017 and May 2025. Patients requiring valve reintervention were included in the analysis.

Results: Eighteen aortic valve repairs were performed in 17 patients (mean age, 54 ± 15 years; 16 male; 14 tricuspid, 2 bicuspid, one unicuspid), including one redo repair. Ten cases (56%) involved concomitant aortic root remodeling. Tricuspid 21-mm rings were most frequently used (61%). During a mean follow-up of 3.7 ± 1.7 years, 8 reinterventions were required in 7 patients (44%) due to severe aortic insufficiency (n=7) or endocarditis with moderate aortic insufficiency (n=1). The 5-year estimate reintervention rate was 40.8 % (95% confidence interval 20.0-70.5%). Reinterventions included surgical aortic valve replacement (n=5), redo internal geometric annuloplasty (n=1), aortic root replacement (n=1), and valve-in-ring transcatheter aortic valve replacement (n=1). In surgical cases, annular dimensions post-explantation of the ring consistently returned to their pre-implantation sizes.

Conclusions: In our experience, 44% of patients receiving the internal geometric annuloplasty ring required aortic valve reintervention. Although effective in reducing annular size, its rigid intra-annular design and the potential for excessive annular downsizing may predispose to recurrent insufficiency and limit future transcatheter options, prompting careful consideration of its broad application.