Journal of Thoracic and Cardiovascular Surgery最新文献

Objectives: Phantom lymph node collection, defined as intraoperative sampling of tissue presumed to be nodal that, on pathological review, proves to be non-nodal, is a previously understudied outcome in thoracic surgery. This study aimed to quantify its incidence, identify associated factors, and assess its relationship with cancer-specific outcomes.

Methods: We conducted a retrospective cohort study using a meticulously curated Veterans Health Administration dataset of patients undergoing curative-intent non-small cell lung cancer resection between 2018 and 2024. Our primary outcomes included frequency of phantom lymph node collection, along with covariates independently associated with it. Secondary outcomes were overall survival and recurrence-free survival.

Results: A total of 2,972 Veterans were included in this cohort. Phantom lymph node collection occurred in 327 (11.0%) patients. On multivariable analysis, phantom lymph node collection was more likely with lower-lobe tumors (odds ratio, 1.45; 95% CI, 1.13 - 1.88), and less likely among patients who received guideline-concordant nodal sampling (≥3 N2 and ≥1 N1 nodal stations) (odds ratio, 0.56; 95% CI, 0.43 - 0.74). Notably, phantom lymph node collection was not associated with overall (hazard ratio, 0.96; 95% CI, 0.77 - 1.19) or recurrence-free survival (hazard ratio, 0.86; 95% CI, 0.68 - 1.08).

Conclusions: Phantom lymph node collection is common during curative-intent resection of early-stage lung cancer. Although not prognostic, its association with guideline-concordant sampling highlights it as a potential target for surgical quality improvement initiatives.

Objective: Patients on ticagrelor undergoing cardiac surgery before completing guideline-recommended washout are at high risk for severe bleeding. This study evaluated whether a novel drug removal device reduces bleeding in patients operated within 2 days from ticagrelor discontinuation.

Methods: Eligible patients were randomized 1:1 to intraoperative DrugSorb-ATR or sham control. Primary safety endpoint was adverse events at 30 days. Efficacy was assessed by composite endpoints comprising bleeding events using Universal Definition of Perioperative Bleeding (UDPB) and 24-hour chest tube drainage (CTD) in the overall and isolated coronary artery bypass grafting (CABG) populations with a hierarchical win ratio (WR) method.

Results: 140 patients were randomized, 132 had surgery and received a study device; 92% were isolated CABG. Mean age was 65±5 years, 15% females. The primary safety endpoint was met, with similar adverse events between groups. The primary efficacy endpoint was not met in the overall or CABG populations (WR 1.07, 95% CI 0.72-1.58, p=0.748; WR 1.33, 95% CI 0.86-2.04, p=0.202 respectively). The supplementary efficacy endpoint was met in the CABG population (WR 1.59, 95% CI 1.02-2.46, p=0.041) with significant reductions also shown in large CTD bleeding events (p=0.016) and the composite of severe bleeding events or CTD≥1L (p=0.041). The number needed to treat to prevent a severe bleed was 6.

Conclusions: Intraoperative use of DrugSorb-ATR is safe in patients operated within 2 days of ticagrelor discontinuation. Although the primary endpoint was not met in the overall population there were significant reductions in severe bleeding events in the prespecified CABG population.

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.

Objectives: 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 post-transplant outcomes of single LDLLT (SLDLLT).

Methods: A total of 110 LDLLTs, including 16 SLDLLTs and 94 bilateral LDLLTs (BLDLLT), were performed from 2008 to 2021. Patient characteristics and post-transplant outcomes were compared between the two groups.

Results: The SLDLLT group included 14 pediatric patients and two 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 post-transplant outcomes did not differ significantly between the two groups. Retransplantation was performed in three out of four patients who underwent SLDLLT and two out of 19 patients who underwent BLDLLT, all of whom developed chronic lung allograft dysfunction (CLAD). The 5- and 10-year survival rates after SLDLLT were both 93.3% and comparable to those after BLDLLT (P=.057).

Conclusions: SLDLLT may produce acceptable short- and long-term post-transplant outcomes when meticulous anatomical and functional size matching is implemented; nevertheless, retransplantation may be required when CLAD 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.