Annals of Thoracic Surgery最新文献

Background: Current guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) for patients age ≤65 years. Recent state-specific data suggest over 50% of patients age ≤65 years undergo TAVR. Given recent data of a potential survival benefit for mechanical SAVR in patients aged 60 years and younger, we sought to evaluate the national incidence of TAVR, bioprosthetic SAVR, and mechanical SAVR in young patients.

Methods: Using the PREMIER Health Database, all patients aged 40-65 years undergoing isolated AVR (2016-2024) were assessed. PREMIER is a nationally representative all-payer, all-age, inpatient and outpatient database accounting for 25% of United States population. Diagnosis-related group and International Classification of Diseases 10th revision procedure codes were used to define procedures and comorbidities and a validated frailty metric.

Results: A total of 18,694 patients receiving first-time isolated aortic valve replacement were analyzed (31.3% TAVR, 68.7% SAVR). Patients receiving TAVR were older, female, black with higher Kim frailty index (p < 0.0001). Young patients were more likely to receive TAVR at teaching hospitals and larger centers (>499 beds). TAVR increased from the beginning of the study period to a peak of 40.8% in 2020 followed by a decrease to 32.5% in 2024. Overall utilization of mechanical SAVR remained between 15-18% throughout.

Conclusions: Nearly one third of patients aged 40-65 years receive TAVR in contemporary practice. Real time data highlight that evolving TAVR use outside of current guidelines is less that previously reported in regional datasets.

Redo surgical Aortic Valve Replacement (AVR) should be favored over Transcatheter Aortic Valve Replacement (TAVR), especially in patients who have prosthetic aortic valves that cannot be fractured in whom implantation of a small sized TAVR would lead to patient prosthetic mismatch; adversely affecting the quality of life.

Background: Neoadjuvant chemoimmunotherapy (NCI) and targeted therapy (NTT) are cornerstone treatments for locally advanced lung adenocarcinoma. However, their impact on surgical feasibility and long-term survival outcomes remains unclear.

Methods: This dual-center retrospective study included patients with LA who underwent radical surgery following NCI (n=97) or NTT (n=105) from January 2020 to December 2022 in the Cancer Hospital Chinese Academy of Medical Sciences and First Affiliated Hospital of China Medical University. Surgical outcomes (minimally invasive surgery rate, conversion to thoracotomy rate, complications), pathological response of tumor bed and metastatic lymph nodes, and survival outcomes [3-year overall survival and recurrence-free survival] were compared between two groups.

Results: Compared with NCI group, the NTT group had a lower conversion rate (8.6% vs. 18.6%, P=0.04), reduced postoperative drainage volume (180 mL vs. 240 mL, P<0.01), and lower incidence of postoperative pneumonia (2.9% vs. 10.3%, P=0.03). The NCI group demonstrated a higher major pathological response rate (9.3% vs. 1.9%, P=0.02). The NTT group achieved superior 3-year recurrence-free survival (73.4% vs 58.6%, P=0.03) compared with NCI, with particularly pronounced survival benefits in the gene mutation-positive subgroup (3-year overall survival: 89.5% vs 78.9%, P=0.01; 3-yearrecurrence-free survival : 72.0% vs 53.7%, P=0.02).

Conclusions: For patients with lung adenocarcinoma, NTT is associated with reduced surgical complexity, lower conversion rates, and fewer postoperative complications compared with NCI. Additionally, NTT is correlated with long-term survival benefits, particularly in patients with gene mutations.

Background: Choosing between mechanical and bioprosthetic valves for aortic valve replacement (AVR) or mitral valve replacement (MVR) remains challenging, particularly for patients with end-stage renal disease (ESRD). Patients with ESRD have an increased risk of bleeding due to simultaneous anticoagulation therapy and accelerated valve calcification, which can complicate valve selection.

Methods: In this nationwide retrospective cohort study, we used data from Taiwan's National Health Insurance Research Database. We included patients who underwent AVR or MVR from 2001 to 2020. Propensity score matching and inverse probability of treatment weighting were applied to mitigate confounding factors.

Results: We included 16649 patients: 9758 who underwent single AVR and 6891 who underwent single MVR. In patients with ESRD, bioprosthetic valves were associated with lower all-cause mortality than were mechanical valves. The optimal age cutoffs for patients with and without ESRD were 63 and 66 years for AVR, respectively, and 54 and 70 years for MVR, respectively. Patients with ESRD had higher rates of adverse outcomes, including major bleeding and redo valve surgeries. The lower age cutoff for MVR in patients with ESRD suggests earlier use of bioprosthetic valves may offer benefits in this population.

Conclusions: The presence of ESRD significantly influences whether mechanical or bioprosthetic valves are most appropriate, and treatment strategies should be individualized. Bioprosthetic valves may improve outcomes for patients with ESRD by reducing mortality and bleeding risk. However, further research is required to refine valve selection guidelines for this high-risk population.

Background: The Mesothelioma and Radical Surgery 2 (MARS2) trial has drawn into question pleurectomy/decortication (PD) for the treatment of pleural mesothelioma. This trial's evaluation of resectability (poor PET-CT utilization, patients with non-epithelioid subtypes, etc.) and preference for extended PD (89% patients underwent this) may have led to the high in-hospital and 30-day mortality (both 4%) and 90-day mortality (9%). Many argue that surgical treatment for mesothelioma offers better outcomes in appropriately identified patients. The argument is based on case series prior to 2015 with limited discussion of surgical details. We present our institutional outcomes in carefully-characterized pleural mesothelioma during the time MARS2 was completed, highlighting management and outcomes in the same period.

Methods: Our database was screened for patients from 2015-2021 treated with PD for pleural mesothelioma. Patients undergoing extrapleural pneumonectomy were excluded. Electronic medical records were queried for dates of surgery, last follow-up, and death; preoperative tests; operative details; and postoperative outcomes. Electronically available obituaries were reviewed to supplement survival data. Descriptive variables and post-surgical survival were analyzed.

Results: Seventy-one patients underwent PD for pleural mesothelioma. Histological diagnosis demonstrated 56 (78.9%) epithelioid, 13 (18.3%) biphasic, and 2 (2.8%) sarcomatoid PM. All 71 (100%) had pulmonary function tests and PET-CT. In-hospital and 30-day mortality were 0 and 90-day mortality was 3/71 (4.2%).

Conclusions: PD can be done safely, with low post-operative mortality. With strict selection criteria and resection focused on balancing cytoreduction with patients' tolerance for aggressive surgery, short-term complications and mortality of PD in pleural mesothelioma can be limited.

Background: Computed tomographic (CT) lung cancer screening (LCS) reduces lung cancer-specific mortality and improves survival. We reviewed contemporary literature to develop consensus recommendations on perioperative quality standards for LCS programs to optimize outcomes.

Methods: The Society of Thoracic Surgeons (STS) Task Force on Lung Cancer Screening and STS Workforce on Evidence Based Surgery convened a multidisciplinary panel of thoracic surgeons, radiation oncologists, and interventional pulmonologists. A comprehensive literature review was conducted using the Population-Intervention-Comparisons-Outcome framework. Consensus statements were developed through a modified Delphi process addressing: 1) preoperative biopsy and diagnostic surgical procedures, 2) acceptable rates of complications from diagnostic and therapeutic procedures, and 3) timing of intervention following a suspicious LCS finding and the role of the multidisciplinary team in patient management. Consensus required ≥75% agreement.

Results: Twenty-three consensus statements were developed after three Delphi rounds; 20 achieved consensus in the first round. Surgery without tissue diagnosis was acceptable for carefully selected patients, favoring minimally invasive, parenchymal-sparing approaches. Pneumonectomy without diagnosis was unanimously rejected. Programs should track benign resection rates. Acceptable complication benchmarks included pneumothorax <5%, hemoptysis <2%, and mortality <1% for bronchoscopic biopsy; and surgical morbidity <10%, 30-day mortality <1%, per STS database standards. Definitive resection should occur within 12 weeks of the inciting imaging study. Multidisciplinary teams should include thoracic surgery, oncology, pulmonology, and radiology. Preoperative pulmonary rehabilitation and smoking cessation were emphasized.

Conclusions: This STS consensus defines perioperative quality standards for CT LCS programs, supporting shared decision-making, multidisciplinary care, and quality improvement.