Journal of Thoracic and Cardiovascular Surgery最新文献

Objectives: Minimally invasive thoracic surgery can cause significant pain, and optimizing pain control after surgery is highly desirable. We examined pain control after intercostal nerve block with or without cryo-ablation of the intercostal nerves.

Methods: This was a randomized study (NCT05348447) of adults scheduled for a minimally invasive thoracic procedure. Each intercostal space near the incision site was injected with lidocaine and bupivacaine with epinephrine (standard-of-care). The cryo-analgesia group also had 5-6 intercostal nerves ablated. The primary outcome was the amount of narcotics (in morphine mg equivalent, MME) taken during the postoperative hospital stay and the first two weeks post-discharge. Secondary outcomes were incentive spirometry (IS) volume and pain scores in the hospital and pain and neuropathy scores at two weeks.

Results: Our final cohort contained 103 patients (52 standard-of-care; 51 cryo-analgesia). There were no differences between the treatment groups in MMEs administered during the hospital stay (44.9 mg standard of care vs. 38.4 mg cryo-analgesia), total MME at two weeks (108.8 vs. 95.2 mg), or pain assessed on postoperative day (POD) 1 (3.8 and 3.3), POD2 (2 and 3.5), or two weeks (2 and 3.5). The decrease in IS in the postoperative period was not significantly different between the two groups. Patients in the cryo-analgesia group had higher neuropathy scores (8 vs. 13, p=0.019) two weeks after surgery.

Conclusions: In this randomized study, cryo-analgesia did not decrease postoperative pain or narcotic requirements. Cryo-analgesia increased neuropathic pain two weeks after surgery.

Objective: Determine the incidence of PSI occurring during perioperative care for lung surgery and their impact on postoperative outcomes at 90 days.

Methods: A multicenter study was conducted in three French thoracic surgery departments. Consecutive patients aged more than 18 years, who had lung surgery (open, video-assisted or robotic) for benign or malignant diseases were included. PSI occurring during lung surgery were reported in Epithor, the French national thoracic database. The primary outcome was the incidence of perioperative PSI. Secondary outcomes were the rates of complications, readmission and mortality at 90 days. All data were prospectively entered in the Epithor database.

Results: From January 1st, 2021, to December 31st, 2021, 1919 surgical procedures were screened and finally, 953 procedures were included. PSI were observed in 305/953 procedures (32%) cumulating a total number of 369 PSI. PSI were related to: human factors in 179/369 (48.5%), organization in 101/369 (27.4%) and technology in 85/369 (23%). PSI were categorized as near-miss events in 97 (26%), no-harm incidents (HI) in 125 (34%), mild HI in 83 (22%), moderate HI in 39 (11%), severe HI in 21 (6%), and mortality in 4 (1%). The relative risk of outcome at 90 days was significantly increased according to PSI severity: no PSI/near-miss vs no-HI/HI: RR 2.02 (95% CI 1.70-2.40) for complications, 2.51 (95% CI 1.57-8.30) for readmission and 3.09 (95% CI 1.15-8.30) for mortality.

Conclusions: Incidence of PSI in thoracic surgery may concern approximately one-third of procedures. Human factors play a crucial role in the occurrence of these PSI.

Objective: This study investigated the outcomes after systemic-to-pulmonary artery shunt (SPS) in patients with biventricular circulation.

Methods: Between January 2014 and June 2023, among 406 patients who underwent SPS, 223 patients pursuing biventricular repair were included. Primary outcome of interest was major adverse shunt-related event (MASE) which was defined as the composite of cardiopulmonary resuscitation, extracorporeal membrane oxygenation, and shunt-related intervention.

Results: The median age and body weight were 30 days and 3.5 kg, respectively. Median ratio of shunt diameter to body weight (mm/kg) was 1.0. The origin of SPS was the subclavian artery in 118 (52.9%), and the innominate artery in 93 patients (41.7%). There were 4 early deaths (1.8%), all of which were preceded by in-hospital MASE resulting from pulmonary overcirculation. There were two interstage deaths (0.9%). Competing risk analysis showed that the probability of biventricular repair at 24 months after SPS was 94.2%. In-hospital MASE occurred in 17 patients, with most cases (n=14, 82.4%) resulting from pulmonary overcirculation. In multivariable analysis, associated genetic or extracardiac anomalies (odds ratio [OR] 4.78; p=0.019), transposition of the great arteries (OR 6.42; p=0.012) and use of cardiopulmonary bypass (OR 7.39; p=0.001) were identified as risk factors for in-hospital MASE. Among 10 cases of inter-stage MASE, 9 cases were successfully managed up to biventricular repair.

Conclusions: In the current era, SPS is a safe and useful option for patients with biventricular circulation. In patients with risk factors for in-hospital MASE, meticulous efforts should be directed towards preventing pulmonary overcirculation to further enhance outcomes.

Objective: Use of the Heart Team has been the standard of care for the treatment of aortic valve disease; however, its efficacy has not been evaluated. We sought to analyze its impact using the TAVR utilization ratio (number of TAVR/total AVR volume) on TAVR, SAVR, and overall AVR outcomes.

Methods: We analyzed all TAVRs and SAVRs sampled by the National Readmissions Database between 2016 and 2020. Hospitals were stratified into quartiles based on their TAVR/AVR ratio. Centers with a ratio below the 1st quartile were considered "low ratio", centers in the 2nd and the 3rd quartile "balanced ratio", and centers above the 3rd quartile "high ratio". Primary outcomes were 30-day mortality and complication rate, which included stroke, renal failure, heart block, pacemaker placement, and valve regurgitation.

Results: For overall AVR outcomes, centers with a balanced ratio had lower mortality compared to centers with low ratio (1.9% vs 2.1%, p=0.01) and lower complication rate compared to centers with high ratio (34.8% vs 36.8%, p<0.001). Centers with a balanced ratio had lower TAVR complication rate compared to centers with low ratio (37.3% vs 39%, p<0.001). For SAVR outcome, centers with an balanced ratio had lower post-SAVR mortality (2.1% vs 2.6%, p<0.001) and complication rate (28.6% vs 30.3%, p<0.001) than centers with high ratio.

Conclusion: Centers with balanced TAVR ratios had superior outcomes compared to centers with low or high ratios. These data support the use of a balanced Heart Team to optimize AVR outcomes.

Objectives: We evaluated the use of systemic therapy and overall survival in patients with resected non-small cell lung cancer (NSCLC) whose pathologic tumor size was within 2mm of a T-stage cutoff.

Methods: Retrospective cohort study using the National Cancer Database of patients who underwent resection of tumors within 2mm of the T1c/T2a, T2a/T2b, and T2b/T3 T-stage cutoffs. Patients with nodal involvement or whose T-stage was based on pathologic features other than tumor size were excluded. A multistate model compared the primary outcomes of systemic therapy and overall survival.

Results: From the NCDB, 18,490 patients were identified: 9,966 at the T1c/T2a cutoff, 5,593 at the T2a/T2b cutoff, and 2,931 at the T2b/T3 cutoff. Peaks in tumor size distribution occurred at 5mm intervals. Based on an expected normalized curve, 2,050 patients (11.1%) may have been under-staged. Use of systemic therapy was higher among patients with larger tumors at the T1c/T2a cutoff (7.1% vs. 8.9%; p<0.001), the T2a/T2b cutoff (20.0% vs. 25.5%; p<0.001), and the T2b/T3 cutoff (31.2% vs. 41.8%; p<0.001). In a multistate model, mortality was higher above the T1c/T2a cutoff (Hazard Ratio [HR] 1.10; p=0.01), T2a/T2b cutoff (HR 1.17; p<0.01), and T2b/T3 cutoff (HR 1.13; p=0.03). In patients who received systemic therapy, this trend was eliminated (HR 1.24; p=0.14, HR 0.79; p=0.07, and HR 1.23; p=0.09, respectively).

Conclusions: Rounding of tumor size for pathologic staging is common. While seemingly trivial, rounding may downstage patients and is associated with decreased rates of adjuvant therapy use and potentially worse overall survival.