Annals of Thoracic Surgery最新文献

Background: Protected Cardiac Surgery is a proactive strategy that applies temporary mechanical circulatory support to prevent perioperative low cardiac output syndrome in high-risk cardiac surgery. Rather than escalating vasoactive agents after hemodynamic decline, the approach emphasizes early identification of physiologic vulnerability and timely initiation of support.

Methods: We conducted a structured literature review of peer-reviewed studies published from 2000 to 2024 on temporary mechanical circulatory support in adult cardiac surgery. Fifty-two studies were selected based on relevance to early or prophylactic support, timing of initiation, risk stratification, and systems of care. Clinical insights from multidisciplinary experts also informed the review framework.

Results: Inotropic escalation after hemodynamic deterioration is consistently associated with poor outcomes. High pharmacologic requirements and severe metabolic derangements predict very high mortality, whereas conventional risk scores often fail to identify vulnerable patients. In contrast, early initiation of mechanical support has been associated with lower in-hospital mortality, reduced dependence on vasoactive agents, and improved recovery. Physiologic markers such as filling pressures and lactate levels may provide earlier signals of circulatory decline. Effective implementation also requires institutional coordination, team-based planning, and regional referral systems.

Conclusions: Protected cardiac surgery reframes success in high-risk cardiac surgery by focusing on recovery rather than survival alone. It integrates physiology-guided support with structured planning and system-level readiness to improve outcomes in vulnerable surgical populations.

Background: The adoption of the robotic platform in thoracic surgery has increased within the last decade. We aim to compare clinical outcomes among facilities who performed lung resections for patients with non-small lung cancer (NSCLC) pre- and post-adoption of robotic surgery.

Methods: A retrospective case-control analysis was conducted utilizing the National Cancer Database from 2010-2021. Facilities that performed >/=90% of robotic lung resections for at least 2 consecutive years in 2016 or afterwards were deemed sustained adopters. Time periods for facilities were categorized by pre-transition (<50% usage), transition (50-90%) and post-transition (>/= 90%). Primary (30- and 90-day mortality) and secondary outcomes (30-day readmission, robot-to-open conversion, margin positivity, mean lymph nodes sampled, pathological upstaging) were analyzed pre- and post-adoption.

Results: Within our cohort, 57 facilities met criteria with 24,909 cases. Of these, 12,181 occurred in the pre-transition period (robotic usage [RU]8.6%), 7,440 in the transition period (RU 79.6%), and 5,288 in the post-transition period (RU 93.6%). Compared to control facilities, a greater proportion of study facilities experienced decreases in 30-day (70% vs 63.2%) and 90-day mortality (72.5% vs 52.6%) post-transition. A smaller proportion of study facilities showed decreases in mean lymph nodes sampled (17.5% vs 38.2%) and pathological upstaging (23.2% vs 40.7%) compared to control facilities.

Conclusions: Facilities who sustained adopted robotic surgery may be associated with decreased short-term mortality rates and higher rates of lymph nodes sampled and pathological upstaging. Continued uptake of robotic platforms in thoracic surgery is not only safe but may provide mortality and oncologic benefit.