Journal of Thoracic and Cardiovascular Surgery最新文献

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.

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

Methods: In 4027 surgically resected primary nonmucinous lung adenocarcinomas, we analyzed the prevalence of spread through air spaces according to driver mutation status (EGFR, KRAS, ALK, ROS1) across different tumor sizes and stages. Subsequently, we compared the prognostic value of spread through air spaces for predicting 5-year cumulative incidence of recurrence according to EGFR mutation status.

Results: Spread through air spaces was present in 1619 (40.2%) adenocarcinomas, with its prevalence increasing with larger tumor size and higher pathologic stage. Spread through air spaces 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, spread through air spaces 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, spread through air spaces was strongly associated with higher 5-year cumulative incidence of recurrence in the 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 spread through air spaces varied by driver mutation status, suggesting that the clinical interpretation of spread through air spaces may depend on the molecular context.

Purpose: A leukocyte filter has been empirically incorporated within ex vivo lung perfusion circuits since the advent of ex vivo lung perfusion. However, the utility of the leukocyte filter 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 leukocyte filters on ex vivo lung perfusion and evaluated whether a conventional arterial filter would prove to be noninferior.

Methods: Porcine donor lungs (n = 22) were extracted and placed on the Toronto ex vivo lung perfusion platform for 12 hours. Groups consisted of a leukocyte filter group (conventional ex vivo lung perfusion with a leukocyte filter), an arterial filter group (the conventional leukocyte filter was replaced with an arterial filter), a change of filter group where the leukocyte filter was clamped and exchanged for a fresh filter after 1 hour, and a no filter control group. Because of severely poor performance seen in the change of filter group, only lungs in the leukocyte filter, arterial filter, and no filter groups were then transplanted into porcine recipients and monitored during a 4-hour reperfusion period.

Results: The leukocyte filter, arterial filter, and no filter groups showed good lung function on ex vivo lung perfusion. The change of filter group demonstrated worse lung function on ex vivo lung perfusion. After transplant, the leukocyte filter, arterial filter, and no filter groups demonstrated equivalent early lung function performance, but on histological staining, the no filter group demonstrated increased lung injury over the other groups. Cytokine levels were not significantly different among groups.

Conclusions: The traditional leukocyte filter should be used in the ex vivo lung perfusion circuit but can be exchanged for an arterial filter with noninferior performance. Changing the filter after 1 hour does not add therapeutic benefit and makes lung performance worse on ex vivo lung perfusion.

Objective: To evaluate our experience with the management of type A aortic dissection (TAAD) in pregnancy or the postpartum period over 25 years.

Methods: From 1998 to 2023, our team managed 60 pregnant women (mean age, 31.4 ± 5.0 years) who sustained TAAD at mean of 30.3 ± 8.5 gestational weeks (GWs), including 27 in the third trimester (45.0%) and 13 during the postpartum period (21.7%). Marfan syndrome (MFS) was seen in 39 patients (65.0%) with 13 (21.7%) having a family history. Before operation, aortic root diameter averaged 53.6 ± 17.1 mm, which was significantly larger in MFS patients than non-MFS patients (57.0 ± 17.0 mm vs 47.0 ± 15.0 mm, P = .019). Management strategy was based on GW (ie, surgical versus medical treatment, surgery, or delivery first).

Results: One patient was treated medically (1.7%), and 59 were treated surgically (98.3%). Management strategies were single-stage delivery and aortic repair at a mean of 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 a median of 9.5 days. Maternal and fetal mortality rates were 100% (1/1) and 100% (1/1), respectively, 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 a median of 6.7 years (interquartile range, 4.8-10.9 years). Five maternal deaths and 2 fetal deaths occurred. Eight patients underwent a total of 10 reoperations. Ten-year maternal and fetal survival rates were 79.3% and 67.7%, respectively. Eight patients (7 with MFS, 87.5%) underwent 10 reoperations at a median of 4.7 years (IQR, 2.1-9.1 years).

Conclusions: For TAAD occurring after 28 GWs, adequate maternal and fetal survival can be achieved with delivery followed by aortic repair, preferably in one stage. Before 28 GWs, 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 with a root diameter ≤45 mm.