Annals of Thoracic Surgery最新文献

Background: This study aimed to identify the impact of margin distance on locoregional recurrence (LRR) and survival outcomes after thoracoscopic segmentectomy for non-small cell lung cancer.

Methods: We retrospectively analyzed data from prospectively collected consecutive thoracoscopic segmentectomies in a single center from January 2008 to February 2023. The restricted cubic spline of the adjusted Cox regression model for LRR displayed the breakpoint of margin distance. The Kaplan-Meier estimator with log-rank test evaluated the overall survival between the 2 groups stratified by the breakpoint, and the Aalen-Johansen estimator with the Gray test assessed the LRR-free survival and lung cancer-specific survival in the competing model.

Results: The study included 155 patients. LRR was observed in 22 patients (14.2%), with a median time to LRR of 17.1 months (interquartile range, 6.3-26.3 months). Margin distance was found to be a predictor for LRR (hazard ratio, 0.92; P = .033). The identified breakpoint for margin distance in this cohort was 19.8 mm. Compared with this cutoff, a margin distance of 15 mm increased the risk of LRR by 65%, whereas 25 mm decreased the risk to LRR with 31%. A segmentectomy with a margin distance ≥20 mm resulted in significant improvements in overall survival (P = .020), lung cancer-specific survival (P = .010), and LRR-free survival (P < .001) compared with cases with a margin distance of <20 mm.

Conclusions: Margin distance ≥20 mm decreased LRR and improved survival outcomes for thoracoscopic segmentectomy in this study.

Background: This study compares the long-term outcomes of patients after repair of transposition of the great arteries (TGA) with and without aortic arch obstruction (AAO).

Methods: This is a single-institution, retrospective study between October 2004 and February 2023. Patients who underwent arterial switch operation and aortic arch repair (ASO-AAR group) with patch augmentation were compared with those without AAO (ASO group). The primary end point was survival; freedom from reintervention was a secondary end point.

Results: We identified 176 patients, 31 in the ASO-AAR group and 145 in the ASO group. The median follow-up period was 10.3 years. There were no differences between the ASO-AAR group and the ASO group in early deaths (3.2% vs 0.7%) and late deaths (3.2% vs 2.8%), or 15-year survival rates (92.6% vs 96.2%). Surgical and catheter-based reinterventions were higher in the ASO-AAR group, involving the pulmonary arteries (41.9% vs 4.8%, P < .001), aortic arch (16.1% vs 0.7%, P < .001), and residual ventricular septal defects (11.4% vs 0%, P = .05). The ASO-AAR group showed a higher prevalence of double-outlet right ventricle TGA-type (61.3% vs 4.1%, P < .001) and a lower aortopulmonary index (0.67 vs 1.01, P < .001).

Conclusions: Patients undergoing surgical repair of TGA and AAO achieved excellent survival rates, comparable to patients with simple transposition. A higher rate of surgical and catheter-based reinterventions was observed in patients with arch obstruction and/or a low aortopulmonary index. AAR with patch augmentation proved to be an effective surgical technique with a low incidence of aortic reinterventions.

Background: Conduction abnormalities requiring permanent pacemaker (PPM) implantation are common after tricuspid valve operations, although the incidence is variable. This study investigated contemporary rates of and risk factors for a PPM after tricuspid operations.

Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with tricuspid repair or replacement from 2011 to 2020. Factors independently associated with the risk of a postoperative PPM during the index hospital admission were examined using multivariable logistic regression with a complete case approach. Annualized hospital and surgeon volumes were calculated.

Results: We identified 71,937 patients undergoing tricuspid operations. Median patient age was 66 years (interquartile range, 53-74 years), 56% (n = 40,590) were women, and the median ejection fraction was 0.56 (interquartile range, 0.48-0.60). Tricuspid operations were concomitant in 87% (n = 62,457), elective in 62% (n = 44,393), and included repair in 86% (n = 61,720). Overall postoperative incidence of a PPM was 15% (n = 10,857); 13% (n = 8304) after repair and 25% (n = 2553) after replacement; and 4% (n = 174) for isolated tricuspid repair and 24% (n = 1248) for isolated tricuspid replacement. Multivariable analysis showed baseline characteristics, endocarditis, concomitant operations, longer cardiopulmonary bypass time, tricuspid replacement, and lower hospital and surgeon tricuspid operative volumes were independently associated with greater risk for a PPM. After adjustment, tricuspid replacement had 3.2-times greater PPM risk compared with tricuspid repair.

Conclusions: Nationally, 15% of patients undergoing tricuspid operations required postoperative PPM implantation. PPM risk was increased with concomitant valve operations, tricuspid replacement, longer cardiopulmonary bypass time, and operations performed by less experienced surgeons and centers. Innovation is needed to decrease this significant morbidity.

Background: Mechanisms of repair failure after mitral valve repair (MVr) using chordal replacement and annuloplasty for degenerative mitral regurgitation were analyzed.

Methods: All mitral valve reoperations after isolated MVr using solely chordal replacement and annuloplasty for degenerative mitral regurgitation at the German Heart Center Munich (Munich, Germany) were reviewed. This retrospective observational study aimed to analyze mechanisms of repair failure leading to reoperations.

Results: Between 2003 and 2010, a total of 344 patients underwent MVr with chordal replacement and annuloplasty. During a mean follow-up of 9.7 years (range, 0-15.9 years), reoperation on the mitral valve was necessary in 38 (11.0%) cases. Reoperations were performed after a mean of 6.8 years (range, 0-14.1 years). The mechanisms of MVr failure were disease progression (39.5%), technical failure (36.8%), and endocarditis (18.4%). Re-repair was performed in 28.9% and was accomplished using redo annuloplasty (90.9%), chordal replacement (90.9%), resection techniques (27.3%), and leaflet patch reconstruction (9.1%). One patient (2.6%) underwent transcatheter edge-to-edge repair for reoperation. Mitral valve replacement (MVR) was necessary in 63.2%. Redo MVr was mainly performed in cases of technical failure, and MVR was more frequently performed in patients with mitral valve sclerosis. Repeat reoperation was necessary in 3 of 24 cases of MVR and in 2 of 11 cases of redo MVr after a median of 3.8 years (range, 0.01-10.04 years).

Conclusions: MVr using chordal replacement allows a variety of methods for re-repair, including transcatheter solutions. Redo MVr is more often feasible in cases of technical failure, whereas MVR for reoperation is more frequently necessary in patients with mitral valve sclerosis.

Background: Mitral valve repair provides superior outcomes to replacement for primary mitral regurgitation. Whether this is true after previous repair is unknown. This study presents the results of a strategy of rerepair for failed mitral valve repair. The study examined patients who were brought to the operating room for an intended mitral valve rerepair.

Methods: Study investigators reviewed the last decade of institutional mitral valve databases at The University of Pennsylvania (Philadelphia, PA) and Baylor Scott & White The Heart Hospital - Plano (Plano, TX) and identified patients who underwent repeat mitral valve repair, in whom the index operation was mitral valve repair. The study analyzed their operative details and the clinical and echocardiographic outcomes.

Results: Between 2008 and 2021, 71 patients (aged 61.5 ±10.7 years; 20% female) underwent mitral valve reoperation at an mean of 6.24 ± 7.62 years after an index mitral repair. A total of 20% of patients presented with New York Heart Association functional class III or IV symptoms. At the index operation, 34 patients (47.9%) had repair through a right minithoracotomy. Fifteen patients (21.1%) required the reoperation within 1 year. There were 0 early and 8 late deaths. One patient who underwent mitral replacement instead of repair required reoperation for paravalvular leak during the follow-up period. Three patients required mitral valve replacement at an average of 2.28 ± 2.03 years after initial mitral valve rerepair.

Conclusions: Mitral rerepair can be performed with acceptable results at a valve reference center. Durability and functional advantages of this approach remain to be proven.

Background: Despite prospective randomized evidence supporting concomitant treatment of atrial fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management of AF remains. We assessed longitudinal outcomes after surgical treatment of persistent or paroxysmal AF during MV surgery in Medicare beneficiaries.

Methods: All Medicare beneficiaries with a diagnosis of AF undergoing MV surgery (2018-2020) were evaluated. Patients were stratified by no AF treatment, left atrial appendage obliteration (LAAO) alone, or surgical ablation and LAAO (SA+LAAO). Doubly robust risk adjustment and subgroup analysis by persistent or paroxysmal AF were performed.

Results: A total of 7517 patients with preoperative AF underwent MV surgery (32.1% no AF treatment, 23.1% LAAO alone, 44.7% SA+LAAO). After doubly robust risk adjustment, AF treatment with SA+LAAO or LAAO alone were associated with lower 3-year readmission for stroke or bleeding. However, SA+LAAO was associated with reduced 3-year mortality and readmission for AF or heart failure compared with no AF treatment or LAAO alone. Compared with no AF treatment or LAAO alone, SA+LAAO was associated with lower composite end point of stroke (hazard ratio, 0.75) or death (hazard ratio, 0.83) at 3 years. Subgroup analysis identified similar longitudinal benefits of SA+LAAO in patients with persistent or paroxysmal AF.

Conclusions: In Medicare beneficiaries with AF undergoing MV surgery, SA+LAAO was associated with improved longitudinal outcomes compared with LAAO alone or no AF treatment in patients with paroxysmal or persistent AF. These contemporary real-world data further clarify the benefit of SA+LAAO during MV surgery across all types of AF.

Background: Understanding characteristics associated with survival after esophagectomy for cancer is critical to preoperative risk stratification. This study sought to define predictors for long-term survival after esophagectomy for cancer in Medicare patients.

Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients aged ≥65 years who underwent esophagectomy for cancer between 2012 and 2020 and linked to Centers for Medicare and Medicaid Services (CMS) data using a deterministic matching algorithm. Patient, hospital, and treatment variables were assessed using a multivariable Cox proportional hazards model to evaluate characteristics associated with long-term mortality and readmission. Kaplan-Meier and cumulative incidence curves were generated and differences evaluated using the log-rank test and Gray's test, respectively.

Results: After CMS linkage, 4798 patients were included. Thirty-day and 90-day mortality in the study group was 3.84% and 7.45%, respectively. In the multivariable model, American Society of Anesthesiologists score >3, body mass index >35, and diabetes were associated with increased mortality <90 days post-surgery, while pN/pT upstaging was associated with increased mortality >90 days post-surgery. Patients upstaged to pN(+) had a 147% increased mortality risk (adjusted hazard ratio [aHR], 2.47; 95% CI, 2.02-3.02) and those that remained pN(+) a 75% increased mortality risk (aHR, 1.75; 95% CI, 1.57-1.95) compared with downstaged patients. Patients who were pT upstaged had a 109% (aHR, 2.09; 95% CI, 1.73-2.53) increased mortality risk compared with pT downstaged patients. Risk for readmission was independent of procedure type or approach and was higher in c stage ≥2, American Society of Anesthesiologists score ≥4, and pN+.

Conclusions: Medicare patients undergoing esophagectomy for cancer have identifiable patient-specific predictors for short-term mortality and tumor-specific predictors for long-term mortality and readmission. In the absence of pathologic T and N downstaging, risk for long-term mortality and readmission are increased.