Journal of Thoracic and Cardiovascular Surgery最新文献

Objectives: Right minithoracotomy mitral valve surgery has become a minimally invasive alternative to median sternotomy, although long-term outcomes remain incompletely defined. This study compared early and late outcomes of the 2 approaches in patients with degenerative mitral regurgitation.

Methods: A single-center retrospective analysis was performed of 976 patients (mean age 60 ± 13 years) who underwent mitral valve repair, with or without concomitant procedures, between 2001 and 2022. Patients were categorized by surgical approach: sternotomy (n = 437) or right minithoracotomy (n = 539). Early outcomes, long-term mortality, cumulative incidence of mitral-related reintervention, and serial echocardiographic changes were evaluated.

Results: Median (interquartile range) clinical follow-up was 12.8 (8.4-16.6) years in the sternotomy group and 4.9 (3.1-7.1) years in the minithoracotomy group. In the matched cohort, the minithoracotomy approach was associated with shorter operative time and reduced hospital stay. In-hospital mortality was 0% in both approaches. The long-term all-cause mortality and cumulative incidence of mitral-related reoperation were comparable between the approaches. The mixed-effect model indicated both approaches achieved durable mitral regurgitation reduction and favorable left ventricular remodeling, whereas minithoracotomy showed greater reductions in left atrial size and tricuspid regurgitation pressure gradient.

Conclusions: Compared with sternotomy, right minithoracotomy mitral repair provided excellent early safety and faster recovery. Long-term repair durability, reflected by comparable cumulative incidence of mitral-related reoperation, was similar to sternotomy, whereas survival estimates should be interpreted in the context of differential follow-up duration. When performed at experienced centers, minimally invasive mitral valve repair represents a viable alternative for degenerative mitral regurgitation.

Objective: Living-donor lobar lung transplantation (LDLLT) with a single lobar graft is required when a small pediatric patient receives an oversized graft or only one donor is available. This study aimed to evaluate the posttransplant outcomes of single living-donor lobar lung transplantation (SLDLLT).

Methods: A total of 110 LDLLTs, including 16 SLDLLTs and 94 bilateral living-donor lobar lung transplantations (BLDLLTs), were performed from 2008 to 2021. Patient characteristics and posttransplant outcomes were compared between the 2 groups.

Results: The SLDLLT group included 14 pediatric patients and 2 adult patients, whereas the BLDDT group included 20 pediatric patients and 74 adult patients. Median functional size matching with forced vital capacity was similar between SLDLLT (64.5%; range, 38.0%-94.6%) and BLDLLT (65.2%; range, 37.3%-247.3%) (P = .379). Early posttransplant outcomes did not differ significantly between the 2 groups. Retransplantation was performed in 3 of 4 patients who underwent SLDLLT and 2 of 19 patients who underwent BLDLLT, all of whom developed chronic lung allograft dysfunction. The 5- and 10-year survival rates after SLDLLT were both 93.3% and comparable with those after BLDLLT (P = .057).

Conclusions: SLDLLT may produce acceptable short- and long-term posttransplant outcomes when meticulous anatomical and functional size matching is implemented; nevertheless, retransplantation may be required when chronic lung allograft dysfunction develops in a single lobar graft.

Objective: The Fontan operation is the final step in staged palliation for patients with single-ventricle physiology. It has extended their life expectancy and improved their quality of life. However, long-term complications and Fontan failure remain lifelong concerns. We aimed to use machine learning to develop a patient-specific preoperative Fontan failure risk calculator.

Methods: Patient data were obtained from the Australia and New Zealand Fontan Registry (ANZFR). The primary composite end point was Fontan failure, defined as any of death, transplant, Fontan takedown or conversion, protein-losing enteropathy, plastic bronchitis, or New York Heart Association class III/IV. To construct the risk calculator, we first used Cox regression with regularization to predict Fontan failure from 54 preoperative predictors in the ANZFR database. A regularization machine learning tool was used to automate variable selection among many predictors. We then manually added clinically relevant predictors. Six predictors (age, ventricular morphology, primary diagnosis, total anomalous pulmonary venous drainage, Fontan type, and moderate or greater atrioventricular valve regurgitation) were ultimately used in a subsequent multivariable Cox regression (without regularization) to ensure the final risk prediction model was simple and easy to interpret.

Results: Data from 1888 patients over 48 years (1975-2023) were available. The ANZFR collects perioperative and follow-up variables about each patient. After excluding patients with Fontan procedures with an atriopulmonary connection (n = 290) and missing predictors or outcome data (n = 125), data from 1473 patients were used to construct the calculator. Median age at Fontan was 4.5 years (interquartile range, 3.7, 5.6 years). Median follow-up was 11.0 years (interquartile range, 5.3, 17.8 years). Freedom from Fontan failure for the overall cohort at 10, 20, and 30 years was 92% (confidence interval [CI], 90%-93%), 83% (CI, 80%-86%), and 72% (CI, 65%-78%), respectively. External validation in an independent cohort demonstrated acceptable model performance. The risk prediction model was then implemented in a Desktop application using the Shiny library in R and used to develop the preoperative Fontan failure calculator on the basis of the 6 predictors.

Conclusions: Machine learning can be applied to "big data" from a binational Fontan Registry to develop a preoperative, patient-specific Fontan failure risk calculator. The model will continue to learn and improve as more data is added. This is a step toward personalized medicine enabling patient-specific pre-operative counselling and realistic expectations.

Objective: To evaluate whether the impacts of atrial fibrillation (AF) ablation differ between rheumatic and degenerative mitral valve (MV) surgeries, given concerns that atrial fibrosis in rheumatic disease may reduce ablation efficacy.

Methods: Consecutive patients undergoing rheumatic or degenerative MV surgery between 2000 and 2022 were retrospectively examined. The primary end point was death, and the secondary the end point was composite of death, readmission attributable to heart failure, and stroke. In patients with AF, outcomes between ablation and no-ablation groups were compared using inverse probability of treatment weighting to adjust for selection bias.

Results: Among 4232 patients (age 56.3 ± 12.7 years; 2357 female), rheumatic and degenerative MV disease were present in 2606 and 1626 patients, respectively, with preoperative AF more frequent in rheumatic than degenerative disease (71.9% vs 34.6%, P < .001). Overall, rates of primary and secondary end points were greatest in AF without ablation, followed by with ablation and those with sinus rhythm (P < .001 for both). In patients with AF, concomitant ablation was associated with reduced adjusted risks of death (hazard ratio, 0.6; 95% CI, 0.49-0.75, P < .001) and composite outcome (hazard ratio, 0.69; 95% CI, 0.57-0.83, P < .001). In subgroup analyses, no significant interactions were found between valve pathology and ablation for death (P = .35) and composite outcomes (P = .87).

Conclusions: Combining AF ablation in rheumatic MV surgery was associated with significantly improved long-term clinical outcomes, comparable with those observed in degenerative MV disease.