Journal of Thoracic and Cardiovascular Surgery最新文献

Objective: To evaluate outcomes of Da Silva Cone repair (CR) using autologous pericardial patch for septal leaflet augmentation in Ebstein's anomaly (EA) and identify tricuspid valve (TV) morphology associated with patch use.

Methods: A single-site retrospective study included patients undergoing CR for EA from Jan 2016-Nov 2024. Patients with prior Starnes procedure or TV surgery were excluded. Patients were categorized into patch and non-patch groups. The primary outcome was TV function (stenosis or regurgitation) at latest follow-up with a secondary composite outcome including re-operation or >moderate residual tricuspid regurgitation (TR). Adjusted regression analyses identified factors associated with outcomes and patch augmentation.

Results: Of 134 patients identified, 108 were included (50 patch, 58 non-patch). Patch patients were older (13.1 vs. 6.9 years, p=0.04). TR improved from ≥moderate in 78.7% pre-CR to ≤mild in 79.0% at follow-up. TV function and follow-up TV-related re-operation rates (6.0% vs. 1.7%) were comparable between groups (p>0.05) with a median follow-up of 1.1 years (IQR 0.6-3.2). Intraoperative factors associated with patch use were multiple TV orifices (OR=4.24, 95%CI: 1.59-11.27, p<0.01), absence of severe inferior leaflet displacement (OR=3.24, 95%CI: 1.11-9.47, p=0.03), and absence of extreme TV rotation (OR=3.19, 95%CI: 1.21-8.41, p=0.02).

Conclusions: Autologous pericardial patch augmentation of the septal leaflet provides comparable early TV function and freedom from re-operation, making it an effective complement during CR.

Objective: Valve-sparing root replacement (VSRR) is being performed into the eighth decade of life. This study evaluated clinical outcomes in patients aged ≥65 years undergoing VSRR or Bio-Bentall.

Methods: From 2004 to 2021, 801 patients ≥65 years of age underwent root replacement at 2 academic medical centers. Nonelective cases, patients with moderate or greater aortic stenosis, previous aortic valve replacement, and mechanical Bentall procedures were excluded. In total, 330 patients underwent either VSRR (n = 94, 28%) or Bio-Bentall (n = 236, 72%).

Results: The median age of the cohort was 71 (67, 75) years. The VSRR group had less incidence of cerebrovascular disease (3.2% vs 11%, P = .02), bicuspid aortic valves (5.3% vs 16%, P = .01), moderate-to-severe aortic insufficiency (60% vs 76%, P = .002) and previous cardiac surgery (2.1% vs 8.9%, P = .03). Patients who underwent VSRR underwent more partial/total arch replacement (17% vs 5.5%, P = .0009) but had similar cardiopulmonary bypass and crossclamp times. Patients who underwent VSRR had less prolonged ventilation (7.5% vs 18%, P = .01) and shorter lengths of stay (7 vs 9 days, P = .001). Overall, in-hospital mortality was 3% and was similar between VSRR (2.1%) and Bio-Bentall (3.0%) groups (P = .73). Eight patients (2.4%) required reoperation on the aortic valve or proximal aorta during follow-up and was similar between groups. Patients who underwent VSRR had better long-term survival than patients who underwent Bio-Bentall (12-year: 70% vs 59%, P = .03).

Conclusions: In patients ≥65 years of age, elective root replacement with either a VSRR or a Bio-Bentall can be performed with excellent short- and long-term outcomes. In the absence of significant valvular structural degeneration, VSRR is an appropriate strategy for this age group in patients with few comorbidities.

Objective: Neoadjuvant chemoimmunotherapy has improved outcomes in resectable non-small cell lung cancer (NSCLC), yet its real-world implementation is often challenged by surgical delays, immune-mediated fibrosis, and postoperative complications. Smokers with NSCLC, despite a high risk for surgical morbidity, show enhanced responses to neoadjuvant chemoimmunotherapy. This study aimed to identify smoking-associated immune cell determinants that could guide treatment strategies.

Methods: Single-cell RNA sequencing (scRNAseq) was performed on 61 lung tissues from non-smokers and smokers to identify smoking-related immune compositions. The scRNAseq data from 19 invasive lung adenocarcinomas were used to validate their presence in the tumor-immune microenvironment. Bulk RNA sequencing data from 102 resected NSCLC and 24 NSCLC patients treated with neoadjuvant chemoimmunotherapy followed by surgery were used for in silico cellular deconvolution and outcome analyses.

Results: Among 135 lung cellular phenotypes, two natural killer (NK) cell subsets were strongly associated with smoking and chronic obstructive pulmonary disease (COPD) severity. "Stress-responsive" NK (NK_SR) cells exhibited immature features and cytokine-responsive features, and "Adaptive and immunoregulatory NK" (NK_AIR) cells showed mature features and elevated multiple immune checkpoint expression. High intratumoral NK_SR cells correlated with improved survival after surgery, particularly in current smokers. Conversely, tumors with low NK_SR and high NK_AIR cells responded more favorably to neoadjuvant chemoimmunotherapy.

Conclusions: Intratumoral NK cell phenotyping may aid in therapeutic stratification in patients with NSCLC. NK_SR cell preservation predicts benefit from upfront surgery, while NK_AIR cell enrichment indicates improved response to neoadjuvant chemoimmunotherapy. These NK cell profiles may help optimize treatment by balancing therapeutic benefit and risk.

Rationale: Chronic lung allograft dysfunction (CLAD) is the primary cause of long-term mortality after lung transplantation. Aspiration of bile acids has been associated with CLAD and lipidomic dysregulation.

Objective: This study evaluates the role of lipidomics in the diagnosis of CLAD.

Methods: Large airway bronchial wash (LABW) (n=611) samples were obtained from 305 lung transplant recipients at different timepoints. Concentrations of 26 specific lipid subfamilies were obtained using liquid chromatography mass spectrometry. Lipid percentages where stratified by highest tertiles. The primary outcome of interest was development of CLAD from sampling time. Time-to-event analysis was done using Kaplan-Meier functions and a multivariable Cox proportional hazards model adjusting for baseline comorbidities.

Measurements and main results: Samples with CLAD at the time of collection showed higher percentages of hexosylceramides (HEXCER), ceramide (CER), sphingomyelin (SM) and lactosylceramide (LACCER). A high percentage of bismethyl-phosphatidic acid (BMP), CE, phosphatidylethanolamine (PEP), dehydrosphingosine (DHSM), lysophosphatidylethanolamine (LPE), ganglioside (GM3), phosphatidyl-serine (PS) were associated with an increased hazards of CLAD by univariable analysis. High ratio of CER:LACCER (HR: 0.53, 95% CI: 0.36-0.8, P=0.002)) and CER:SM (HR: 0.5, 95% CI: 0.33-0.76, P=0.001) were independently associated with decreased hazards of CLAD. Samples with low CER:LACCER and CER:SM ratio were associated with high airway BA levels.

Conclusions: Airway lipidomic qualitative changes show a distinct phenotype that associate with the presence and risk of development of CLAD. A high CER:LACCER and CER:SM ratio is an independently associates of freedom from CLAD and associate with airway bile acid levels.