Journal of Thoracic and Cardiovascular Surgery最新文献

Objective: To evaluate whether multiarterial grafting provides incremental benefit above single arterial grafting in isolated redo CABG.

Methods: From 1/1980 to 7/2020, 6559 adults underwent 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity-score matched with those undergoing single arterial grafting, with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. Median follow-up was 10 years with 25% followed >17 years. Multivariable multiphase hazard modeling and nonparametric random survival forests for survival were used to identify patients for whom multiarterial grafting was most beneficial.

Results: Among propensity-matched patients, postoperative complications for multiarterial versus single arterial grafting were any reoperation, 50 (2.5%) versus 65 (3.2%); renal failure, 73 (3.6%) versus 55 (2.7%); stroke, 44 (2.2%) versus 38 (1.9%); and deep sternal infection, 36 (1.8%) versus 25 (1.2%). Hospital mortality was 1.7% (n=35) versus 2.8% (n=56) (P=.03). Comparing multiarterial to single arterial grafting, survival at 1 and 3 years was 95% versus 94% and 92% versus 88%, and at 5, 15, and 20 years, survival was 87%, 49%, and 31% versus 82%, 42%, and 25%. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P<.0001).

Conclusions: Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used.

Background: In an effort to enhance recovery after cardiac surgery, intraoperative extubation has been targeted as possibly beneficial. This multi-center cohort study aimed to assess this by evaluating the outcomes of OR extubation versus extubation within six hours of intensive care unit arrival (early ICU extubation). Furthermore, we assessed time to ICU extubation and mortality and morbidity.

Methods: Patients undergoing on-pump cardiac surgery across 79 hospitals between 2011-2020 were included to 1) compare outcomes among OR extubation and early ICU extubation patients, and 2) assess time to overall ICU extubation and outcomes.

Results: The overall study cohort comprised 163,982 patients, including 95,982 patients [ [ OR extubation : n= 2,529 (2.6%)and early ICU extubation : n= 93,453 (97.4%)] who underwent comparison of OR with early ICU extubation. Following overlap weighting, OR extubation patients had longer OR times (5.6 vs. 5.1 hours, p < 0.0001), and higher rates of reintubation (5.2% vs 2.9%, p=0.003), prolonged ventilation (3% vs 2%, p = 0.021), reoperation for bleeding (1.5% vs 0.7%, p < 0,01), pneumonia (1.9% vs. 1.1% , p < 0.006), and greater in-hospital mortality on multivariable regression (OR 1.34, p < 0.001). OR extubation patients at centers with low OR extubation rates (< 10%, N=60) had higher mortality (odds ratio 1.6, p = 0.001). Beyond 22 hours of postoperative ICU ventilation, the risk of morbidity and mortality increased significantly .

Conclusions: Few cardiac surgery patients are extubated in the OR, which is associated with no clinical benefit and with increased morbidity. Cardiac surgery programs should reconsider OR extubation following cardiopulmonary bypass. Additionally, increased intubation time, in particular > 22 hours, is associated with an increase in adverse outcomes.

Objective: We performed an intention-to-treat analysis of initial cannulation strategy to assess the impact on perioperative outcomes in acute type A dissection using multicenter data.

Methods: All patients undergoing surgical repair of acute type A dissection from a multicenter national registry of 9 high-volume aortic centers were analyzed. Cannulation strategies included in the analysis were axillary, femoral, direct aortic, and innominate. Among 950 patients, we excluded those with chronic syndromes, type B dissections, and unknown initial cannulation strategy. Patients with multiple cannulation strategies were included if the sequence in which strategies were initiated was known. The final cohort consisted of 936 patients. Primary outcomes were stroke and death. Multivariable logistic regression was performed to adjust for baseline differences. P values represent Tukey's post hoc comparisons.

Results: Among 936 patients, cannulation strategies in descending order included axillary (n = 502, 53%), femoral (n = 268, 29%), aortic (n = 104, 11%), and innominate (n = 59, 6%). Of these patients, 46 (5%) had a change in the initial cannulation strategy before initiating circulatory arrest, mainly for poor axillary flow or initial femoral cannulation for hemodynamic instability followed by axillary. Patients in the femoral group were younger (61.3 ± 13.8 years) than patients in the aortic group (66.4 ± 12.52 years, P = .01) and more likely to present with malperfusion (n = 123, 45.9%) compared with patients in the aortic, axillary, and innominate groups (P < .01). Patients in the femoral group also had the longest duration of cerebral ischemia (femoral: 16.9 ± 16 minutes, aortic: 11.5 ± 11.8 minutes; axillary: 4.41 ± 10.3 minutes; innominate: 2.53 ± 6 minutes, P < .01 for all vs femoral). Unadjusted risk of death, stroke, and prolonged ventilation was lowest in the axillary and innominate groups. Length of stay was also reduced in the innominate group. Multivariable regression demonstrated axillary (odds ratio [OR], 0.52; 0.36-0.75; P = .004) and innominate (OR, 0.19; 0.07-0.54; P = .009) cannulation to be associated with a significantly reduced risk of stroke. A nonsignificant indication of reduced death in patients receiving axillary cannulation remained (OR, 0.66; 0.45-0.96; P = .07).

Conclusions: In high-volume aortic centers, an initial cannulation strategy using axillary access is associated with reduced risk of stroke compared with femoral access. Axillary cannulation should be the preferred strategy in experienced centers if anatomy and stability allow.

Objective: The study objective was to investigate the association between female sex and 30-day mortality and postoperative complications in patients undergoing scheduled proximal thoracic aortic surgery in Sweden.

Methods: In a nationwide population-based cohort study, all patients who underwent scheduled proximal thoracic aortic surgery in Sweden between 2016 and 2020 were included. The primary outcome measure was 30-day mortality. Secondary outcome measures included a combined end point including 30-day all-cause mortality, postoperative new-onset dialysis, perioperative stroke, or a prolonged need of postoperative ventilation (>48 hours). Logistic regression models and propensity score matching were used to estimate the association between female sex and primary and secondary outcomes adjusted for differences in baseline characteristics.

Results: A total of 2000 patients (29% women) were analyzed. The crude 30-day all-cause mortality rate was higher in women compared with men (3.1% vs 1.4%, P < .001). Women were older at the time of surgery (65.6 vs 60.2 years, P < .001) and had more comorbidities and a larger maximum indexed aortic diameter (cm/m body height) at the time of surgery (3.4 ± 0.56 vs 3.0 ± 0.48, P < .001). The adjusted risk for 30-day mortality for women compared with men was not significant (odds ratio, 1.41; 95% CI, 0.70-2.83), and neither was the secondary composite end point (odds ratio, 0.89; 95% CI, 0.62-1.27). The propensity score-matched analysis showed similar results.

Conclusions: Women who underwent proximal thoracic aortic surgery had a 2-fold higher unadjusted 30-day mortality risk, but the mortality risk was not significantly higher when age and comorbidities was taken into consideration.

Objective: To explore the characteristics and prognostic impact of chronic lung allograft dysfunction (CLAD) after deceased-donor lung transplantation and living-donor lobar lung transplantation, wherein the lower lobes from 2 donors are usually transplanted into one recipient.

Methods: The clinical data of 123 deceased-donor and 67 living-donor lung transplantations performed in adult patients at our institution between June 2008 and September 2019 were retrospectively reviewed. The cumulative incidence of CLAD was evaluated on a per-recipient and per-donor graft basis using the Kaplan-Meier method.

Results: A smaller number of human leukocyte antigen mismatches, shorter ischemic time, and lower incidence of grade 3 primary graft dysfunction were observed in living-donor transplantation than in deceased-donor transplantation (P < .001). Restrictive allograft syndrome-type CLAD occurred in 9 (20.9%) of 43 patients with CLAD after deceased-donor transplantation and 9 (45.0%) of 20 patients with CLAD after living-donor transplantation. CLAD occurred unilaterally in 15 patients (75.0%) after bilateral living-donor transplantation. Despite the greater incidence of restrictive allograft syndrome-type CLAD after living-donor transplantation, the overall survival rates after the transplantation and survival rates after the onset of CLAD were comparable between the patients receiving deceased-donor transplants and living-donor transplants. The cumulative incidence of CLAD per recipient was similar between recipients of deceased-donor and the living-donor transplants (P = .32). In the per-donor graft analysis, the cumulative incidence of CLAD was significantly lower in the living-donor grafts than in the deceased-donor grafts (P = .003).

Conclusions: The manifestation of CLAD after living-donor lobar lung transplantation is unique and differs from that after deceased-donor lung transplantation.