Journal of Thoracic and Cardiovascular Surgery最新文献

Objective: To leverage a large clinical registry of pediatric cardiac critical care patients to better understand current practices related to the diagnosis and management of patients with diaphragm dysfunction (DD) following congenital heart surgery (CHS).

Methods: Pediatric Cardiac Critical Care Consortium registry data for August 2014 to September 2022 were evaluated. Patient characteristics and hospital courses were evaluated relative to the development of DD. Date stamps described the relationship between index procedure and date of DD diagnosis, date of diaphragm plication, and outcomes. Risk factors for the development of DD were identified from patient and procedural variables via a 2-step, 2-level logistic regression with hospital random effect.

Results: Among 77,383 unique patients undergoing an index operation, 1130 patients (1.5%) were found to have DD. Of these, 510 patients (45%) underwent plication. Risk factors for DD included younger age and higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category. Patients with DD had longer mechanical ventilation duration, higher incidence of major complications, and longer cardiac intensive care unit and hospital length of stay, although the significance of this correlation is unclear given potential ascertainment bias and residual confounding. The median date of diagnosis was postoperative day 7 (interquartile range [IQR], days 4-13), and the median date of plication was postoperative day 14 (IQR, days 9-24). Patients undergoing plication did not have higher rates of major complications.

Conclusions: Patients with DD exhibit multifaceted clinical features that warrant individualized treatment considerations to optimize clinical outcomes. Neonatal age, functionally univentricular surgery, and failed extubation were found to be important triggers for pursuing a diagnosis and considering surgical plication.

Objectives: The role of adjuvant immunotherapy following neoadjuvant chemoimmunotherapy for resectable non-small cell lung cancer is a critical clinical question. This study aimed to develop a risk stratification model based on pathological response and ypN status after neoadjuvant chemoimmunotherapy to identify patients who would derive the most benefit from adjuvant immunotherapy.

Methods: This multi-center, retrospective study included 363 patients with resectable non-small cell lung cancer (clinical stage IB-III) who underwent neoadjuvant chemoimmunotherapy followed by curative-intent surgery between January 2020 and December 2024. Patients were stratified into four groups based on MPR and ypN status. The efficacy of adjuvant immunotherapy on survival was evaluated for each group.

Results: After a median follow-up of 27.8 months, adjuvant immunotherapy conferred no survival benefit in the overall cohort. However, the proposed MPR-ypN classification effectively identified patients most likely to benefit from adjuvant immunotherapy. The survival benefit from adjuvant immunotherapy was observed exclusively in the non-MPR ypN+ group, which demonstrated significantly improved recurrence-free survival and overall survival. Further analysis revealed that this survival benefit was driven by significant reductions in the risks of both distant metastasis and locoregional recurrence. In contrast, no survival benefit was observed in the MPR ypN0, non-MPR ypN0, or MPR ypN+ group, suggesting that adjuvant immunotherapy may be unnecessary for patients who achieve either a MPR or nodal clearance.

Conclusions: The MPR-ypN-based pathologic classification could effectively identify patients most likely to benefit from adjuvant immunotherapy. This approach established a selective treatment paradigm, reserving adjuvant immunotherapy for the non-MPR ypN+ population while potentially sparing the subgroup unlikely to derive additional benefit from unnecessary treatment and associated side effects.

Objective: Pathologic complete response (pCR) after neoadjuvant therapy predicts favorable outcomes in esophageal squamous cell carcinoma (ESCC). In this era of neoadjuvant immunochemotherapy (nICT), the prognosis of patients achieving nICT-induced pCR remains unclear. This study aimed to characterize recurrence patterns and identify prognostic factors in this population.

Methods: A multicenter retrospective cohort study was conducted across 26 Chinese centers from 2019 to 2023. Patients with ESCC who underwent surgery after nICT and achieved pCR were included. Prognostic factors for recurrence-free survival (RFS) and overall survival (OS) were evaluated using Cox regression analysis.

Results: Among 2135 patients receiving nICT, 474 (22.2%) achieved pCR. After a median follow-up of 32.8 months, 60 patients (12.7%) experienced recurrence, with a median interval of 17.8 months (interquartile range, 8.7-26.7) after surgery. Most recurrences (75%) occurred within 2 years, predominantly as distant metastases (63.3%), with the lung being the most common site. The 2-year RFS and OS were 89.6% and 92.1%, respectively. Advanced clinical nodal stage (cN2-3) was identified as an independent prognostic factor for inferior RFS (adjusted hazard ratio, 1.83; 95% CI, 1.10-3.05; P = .02) but not OS, whereas adjuvant treatment was not associated with improved survival (adjusted hazard ratio, 1.29; 95% CI, 0.69-2.42; P = .42).

Conclusions: Patients with ESCC achieving pCR after nICT exhibited excellent short-term survival but a persistent risk of distant recurrence. Advanced clinical nodal stage is associated with higher recurrence risk, which warrants further validation. Risk-adapted postoperative management may be preferable to routine adjuvant treatment.

Objectives: Goal-directed perfusion strategies during cardiopulmonary bypass typically target indexed oxygen delivery thresholds to reduce acute kidney injury and other complications. This delivery-only paradigm may not fully reflect patient-specific metabolic demand. The oxygen extraction ratio integrates delivery and consumption and may better reflect perfusion adequacy. We tested the hypothesis that intraoperative oxygen extraction ratio is associated with postoperative outcomes.

Methods: We retrospectively analyzed 885 adults who underwent isolated coronary artery bypass grafting (October 2021 to July 2025). Unsupervised clustering identified distinct extraction ratio trajectory phenotypes. Baseline, intraoperative, and postoperative variables were compared across phenotypes, and weighted logistic models assessed associations with Society of Thoracic Surgeons major morbidity or mortality and acute kidney injury. An exploratory subgroup analysis evaluated whether maintaining higher indexed oxygen delivery mitigated risk in patients with elevated extraction ratio.

Results: Three oxygen extraction ratio trajectories were identified: low (mean 21%), moderate (mean 23%), and high (mean (24.4%). Patients with high extraction ratio had more anemia, diabetes, and heart failure and lower average oxygen delivery. After adjustment for baseline risk, high extraction ratio was associated with greater morbidity and mortality (odds ratio, 2.04 [1.5-2.8], P < .001) and acute kidney injury (odds ratio, 1.6 [1.2-2.1], P < .001). In the high extraction ratio group, maintaining an indexed oxygen 300 mL/min/m² or greater for 92% or more of cardiopulmonary bypass time would have relatively reduced the incidence of acute kidney injury (relative risk reduction, 66.8%; 13.9-97.9) and morbidity and mortality (63.8%; 15.2-96.8).

Conclusions: Elevated oxygen extraction ratio was independently associated with postoperative morbidity and acute kidney injury. Incorporating extraction ratio into goal-directed perfusion frameworks may enable a more individualized, physiology-guided perfusion strategy.

Objective: Diastolic heart failure with preserved ejection fraction secondary to coronary artery disease is associated with a significant morbidity and mortality. Diastolic dysfunction due to chronic myocardial ischemia is an important clinical entity though recovery of diastolic relaxation with revascularization is poorly understood. A swine model of hibernating myocardium (HM) was used to assess systolic and diastolic myocardial recovery following coronary artery bypass grafting (CABG).

Methods: Study animals included 18 juvenile pigs who underwent placement of a constrictor around the left anterior descending artery to gradually create chronic ischemia without infarction. Study groups included 5 healthy age- and weight-matched controls, 6 HM animals without revascularization, 7 HM + CABG + 1 month recovery and 5 HM + CABG + 3 months recovery. Cardiac magnetic resonance imaging was used to assess global systolic and diastolic function at rest and with dobutamine stress. Histopathology assessed tissue structural and molecular changes.

Results: Systolic and diastolic myocardial function were significantly depressed in HM. Both improved with CABG; however, diastolic relaxation remained significantly impaired even at 3 months post-CABG compared with controls. Histological analysis showed interstitial fibrosis in HM tissue with residual fibrosis seen post-CABG. Alpha-smooth muscle actin stain identified myofibroblasts in both HM and post-CABG animals.

Conclusions: In a large animal model of HM, diastolic dysfunction persists under stress despite CABG and is present even after 3 months of recovery. Persistent fibrosis and diastolic stiffness prevent full recovery. These findings highlight a therapeutic need for pharmacologic or regenerative adjunctive therapies at the time of revascularization.

Objective: Mitral valve repair (MVr) is the standard treatment for degenerative mitral regurgitation (MR). However, MR may recur, and reoperation is associated with increased mortality and technical complexity. Micro-invasive MVr using the NeoChord technique in redo setting is performed off-pump, offering clear advantages, particularly in high-risk patients.

Methods: This retrospective, multicenter, international registry included 92 patients treated with NeoChord between 2014 and 2025 for recurrent MR following prior MVr across 32 centers. The primary composite endpoint was freedom from recurrence of severe MR, need for reintervention due to technical failure, and 30-day or cardiovascular mortality.

Results: NeoChord repair was successful in 91 patients (98.9%); one was converted to open surgery. Mean age was 64.6±11.6; 22 patients (23.9%) were female. Mean left ventricle ejection fraction was 57.4±8.1%; EuroSCORE II was 4.3±3.2%. A median of three chords was implanted. Mean procedural time was 139±65 minutes. At discharge, MR was ≤mild in 93.5%. One patient (1.1%) died on day eight. One life-threatening bleeding and one acute myocardial infarction were reported. Median hospital length-of-stay was five days; 47.8% were extubated in the operating room. The primary endpoint was achieved in 81.3±6.6% of patients at 5-year (Kaplan-Meier analysis). Seven patients (8.6%) underwent re-reintervention; three remained with severe MR. In the multivariate analysis older age was associated with an increased risk (HR=1.160,95%CI:1.021-1.317), while higher hemoglobin levels were protective (HR=0.423,95%CI:0.233-0.768).

Conclusions: Micro-invasive NeoChord repair provides excellent procedural and 5-year outcomes with very low mortality, supporting its role as a valuable option for reoperative mitral valve surgery.