Journal of Thoracic and Cardiovascular Surgery最新文献

Objective: We aimed to characterize the variation in STAS prevalence by oncogenic driver mutation status in lung adenocarcinoma and to examine whether the prognostic impact of STAS differs according to driver mutation status.

Methods: In 4,027 surgically resected primary non-mucinous lung adenocarcinomas, we analyzed the prevalence of STAS according to driver mutation status (EGFR, KRAS, ALK, ROS1) across different tumor sizes and stages. Subsequently, we compared the prognostic value of STAS for predicting 5-year cumulative incidence of recurrence (CIR) according to EGFR mutation status.

Results: STAS was present in 1,619 (40.2%) adenocarcinomas, with its prevalence increasing with larger tumor size and higher pathologic stage. STAS prevalence varied significantly by driver mutation status, occurring in all ROS1-rearranged tumors (16/16), 80.0% of ALK-rearranged, 56.7% of KRAS-mutated, and 36.6% of EGFR-mutated tumors. Among EGFR-mutated tumors, STAS was less frequent in those with L858R mutation (30.7%) than in tumors with exon 19 deletion (41.2%) or other subtypes (40.7%) (P < .001). These differences were primarily observed in early-stage (stage I) and small (≤ 2 cm) tumors. Despite its lower prevalence, STAS was strongly associated with higher 5-year CIR in stage IA EGFR-mutated subgroup (16.9% vs 1.7%, P < .001). In contrast, no significant association was found in the EGFR wild-type cases (5.7% vs 3.2%, P = .239).

Conclusions: The prevalence and prognostic significance of STAS varied by driver mutation status, suggesting that the clinical interpretation of STAS may depend on the molecular context.

Purpose: A leukocyte filter (LF) has been empirically incorporated within ex vivo lung perfusion (EVLP) circuits since the advent of EVLP. However, the utility of the LF has never been fully defined and studies have questioned the beneficial effects of the filter. Additionally, there have been suggestions that such filters may become quickly saturated in use requiring replacement for better effect. Thus, we sought to determine the effects of LFs on EVLP and evaluated whether a conventional arterial filter (AF) would prove to be noninferior.

Methods: Porcine donor lungs (n=22) were extracted and placed on the Toronto EVLP platform for 12h. Groups consisted of a LF group (conventional EVLP with a leukocyte filter), an AF group (the conventional leukocyte filter was replaced with an arterial filter), a change of filter group (CF) where the leukocyte filter was clamped and exchanged for a fresh filter after 1h, and a no filter (NF) control group. Due to severely poor performance seen in the CF group, only lungs in the LF, AF, and NF groups were then transplanted into porcine recipients and monitored during a 4h reperfusion period.

Results: The LF, AF and NF group showed good lung function on EVLP. The CF group demonstrated worse lung function on EVLP. After transplant, LF, AF, and NF groups demonstrated equivalent early lung function performance, but on histological staining, the NF group demonstrated increased lung injury over the other groups. Cytokine levels were not significantly different between groups.

Conclusions: The traditional leukocyte filter should be used in the EVLP circuit but can be exchanged for an arterial filter with noninferior performance. Changing the filter after one hour does not add therapeutic benefit, and in fact, makes lung performance worse on EVLP.

Objective: We seek to evaluate our experience with management of type A aortic dissection (TAAD) in pregnancy or postpartum over 25 years.

Methods: From 1998 to 2023, our team managed 60 pregnant women (age 31.4 ± 5.0 years) sustaining TAAD at mean 30.3 ± 8.5 gestational weeks (GWs) (27 in third trimester [45.0%]; 13 during postpartum [21.7%]). Management strategy was based on gestational weeks (i.e. surgical versus medical treatment, surgery or delivery first).

Results: Patients were treated medically in 1 (1.7%) and surgically in 59 (98.3%). Management strategies were single-stage delivery and aortic repair at 32.4 ± 4.5 GWs in 29 (48.3%); delivery first at 35 ± 8 GWs in 18 (30%) followed by aortic repair after a median of 6.2 days; and aortic repair first at 18.6 ± 6.3 GWs in 12 (20%) followed by delivery after median 9.5 days. Respective maternal and fetal mortalities were 100% (1/1) and 100% (1/1) with medical therapy, 11.1% (2/18) and 11.1% (2/18) with delivery first, 3.4% (1/29) and 22.6% (7/31) with single-stage delivery and aortic repair, and 16.7% (2/12) and 66.7% (8/12) with aortic repair-first strategies. Follow-up was 98.1% complete (53/54) at median 6.7 years (IQR 4.8-10.9). Five maternal and 2 fetal deaths occurred. Eight patients underwent ten reoperations. Maternal and fetal survival were 79.3% and 67.7% at ten years, respectively.

Conclusions: For TAAD occurring after 28 gestational weeks, maternal and fetal survival can be adequately achieved with delivery followed by aortic repair, preferably in one stage; before 28 gestational weeks, maternal survival should be prioritized given the high uncertainty of fetal survival. Prophylactic aortic repair may be reasonable for women with Marfan syndrome contemplating pregnancy when the root diameter is 45 mm or even smaller.