Annals of Thoracic Surgery最新文献

Background: The Medtronic Freestyle is widely used for full-root aortic valve replacement, offering excellent hemodynamics. However, structural valve deterioration, including pseudoaneurysm formation, raises concerns.

Methods: Our single-center retrospective and prospective cohort study of adult patients who underwent modified Bentall procedures with the Medtronic Freestyle between September 2015 and November 2023 analyzed early and late complications, echocardiographic results, and survival. A cross-sectional computed tomography angiography (CTA) evaluation assessed postoperative structural abnormalities.

Results: 153 patients were included (median EuroSCORE II 3.4%). One- and 5-year actuarial survival rates were 96.7% and 87.2%. Postoperative mean and maximal transvalvular gradients were 5.8 (interquartile range (IQR) 3.3) and 11.1 mmHg (IQR 6.6). Of the 98 patients (77.8% of eligible patients) who underwent CTA imaging, 23.5% had structural abnormalities. Pseudoaneurysms were the most common (15.3%) and warranted reintervention in 3 cases. Routine echocardiography failed to detect them. Multivariate analysis identified previous cardiac surgery as an independent predictor of pseudoaneurysm development (odds ratio 4.32, p=0.046). The cumulative risk of CTA-detectable structural abnormalities may reach 22.7% at 5 years.

Conclusions: The Medtronic Freestyle displays excellent hemodynamic performance. However, silent structural deterioration is not rare. Routine echocardiography may miss these lesions, supporting the role of systematic postoperative CTA imaging, especially for redo patients. Further studies are needed to guide optimal imaging surveillance protocols.

Background: To address the risk of cerebral infarction from pulmonary vein stump thrombosis (PVST) after lung lobectomy, this study evaluated D-dimer measurement as an early screening tool, given that routine contrast-enhanced computed tomography is impractical.

Methods: We retrospectively reviewed 198 patients who underwent lung lobectomy and postoperative contrast-enhanced computed tomography between January 2021 and August 2024. D-dimer levels were measured on postoperative day 1. Receiver operating characteristic curve analysis evaluated D-dimer's discriminative ability, and multivariable logistic regression identified independent risk factors for PVST, which were diagnosed on postoperative day 5-7 using computed tomography.

Results: PVST was detected in 38 of 198 patients (19.2%), typically associated with left upper lobectomy and long pulmonary vein stumps. Postoperative day 1 D-dimer levels were significantly higher in the thrombosis-positive group (median 1.8 vs. 1.3 μg/mL, p<0.001) but did not correlate with thrombus volume. Receiver operating characteristic analysis yielded an area under the curve of 0.692; a negative cutoff of 1.2 μg/mL provided a negative predictive value of 96.9%. Multivariable analysis identified three independent predictors for thrombosis: interstitial pneumonia, left upper lobectomy, and a postoperative day 1 D-dimer level ≥1.2 μg/mL. Overall postoperative complication rates and postoperative hospital duration were similar, although several complications were more frequent in the thrombosis-positive group. Cerebral infarction occurred in four patients (1.6%).

Conclusions: D-dimer measurement on postoperative day 1 shows promise for preliminary PVST screening. However, our single-center retrospective findings require prospective multicenter validation before the 1.2 μg/mL cutoff is implemented in routine practice.

Background: The objective of this study was to evaluate the prognostic value of echocardiographic evidence of left ventricular remodeling for timing of aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis.

Methods: A single-institutional retrospective study including asymptomatic patients with severe aortic stenosis and preserved ejection fraction from 2016-2024 was performed. Patients were stratified into asymptomatic and conservative AVR groups who underwent AVR prior to and after the development of symptoms. The primary outcome was a composite endpoint of mortality, myocardial infarction, stroke, and heart failure re-admission. The incidence of the primary outcome was compared between groups, and the association of echocardiographic parameters with the incidence of the primary outcome was evaluated.

Results: Of 160 patients, 65 (41%) were in the asymptomatic and 95 (59%) were in the conservative AVR group with a median age of 72 [65-78] years. Incidence of the primary outcome was lower in asymptomatic compared to conservative AVR groups (aHR 0.27 [95% CI 0.12 - 0.63], p=0.002). Higher E/e' (aHR 1.39 [95% CI 1.10 - 1.75], p=0.006), indexed LV end-diastolic volume (aHR 1.22 [95% CI 1.00 - 1.47], p=0.04), and indexed LV end-systolic volume (aHR 1.71 [95% CI 1.00 - 2.93], p=0.05) were associated with a higher incidence of the primary outcome.

Conclusions: AVR in asymptomatic patients with severe aortic stenosis improved outcomes with specific echocardiographic parameters as risk factors including higher E/e', indexed LV end-diastolic volume, and indexed LV end-systolic volume. Although additional studies are needed, these findings may assist in patient selection and timing of AVR.