Annals of Thoracic Surgery最新文献

Background: We report our comprehensive approach to the management of patients with hypoplastic left heart syndrome (HLHS) and describe our outcomes in 100 consecutive neonates.

Methods: We stratified 100 consecutive neonates (January 1, 2015 to September 1, 2023, inclusive) into 3 pathways. Pathway 1: 77 of 100 (77%) were standard risk and underwent an initial Norwood Stage 1. Pathway 2: 10 of 100 (10%) were high-risk with noncardiac risk factors and underwent an initial Hybrid Stage 1. Pathway 3: 13 of 100 (13%) were high-risk with cardiac risk factors: 10 underwent an initial Hybrid Stage 1 + Ventricular Assist Device insertion (HYBRID+VAD), and 3 were supported with prostaglandin as a planned bridge to primary cardiac transplantation.

Results: The overall 1-year mortality for the entire cohort of 100 patients was 9% (9 of 100). Pathway 1: Operative Mortality in Pathway 1 for the initial Norwood Stage 1 was 2.6% (2 of 77). Of the 75 survivors of Norwood Stage 1, 72 underwent successful Glenn, 2 underwent successful biventricular repair, and 1 underwent successful cardiac transplantation. Pathway 2: Operative Mortality in Pathway 2 for the initial Hybrid Stage 1 without VAD was 10% (1 of 10). Of 9 survivors of Hybrid Stage 1, 4 underwent successful cardiac transplantation, 1 died while awaiting cardiac transplantation, 3 underwent Comprehensive Stage 2 (with 1 Operative Mortality after Comprehensive Stage 2), and 1 underwent successful biventricular repair. Pathway 3: Of 10 patients supported with initial HYBRID+VAD in Pathway 3, 7 (70%) underwent successful cardiac transplantation and are alive today, and 3 (30%) died on VAD while awaiting transplantation. Median VAD support time was 134 days (range, 56-226 days). Of 3 patients who were bridged to transplant with prostaglandin, 2 underwent successful transplantation and 1 died while awaiting transplantation.

Conclusions: A comprehensive approach to the management of patients with HLHS is associated with an Operative Mortality after Norwood of 2.6% (2 of 77) and an overall 1-year mortality of 9% (9 of 100). Ten patients (10%) were stabilized with HYBRID+VAD while awaiting transplantation. VAD facilitates survival on the waiting list during prolonged waiting times.

Background: Valve preservation in acute type A aortic dissection (ATAAD) can be accomplished with root repair or replacement. Long-term valve durability with root repair has been established, but limited data exist regarding long-term durability of valve-sparing root replacement (VSRR). In this study, long-term results of VSRR were compared with root repair in ATAAD.

Methods: From 2005 to 2023, 866 patients underwent ATAAD repair, of which 675 underwent root repair and 191 underwent root replacement (VSRR, n = 65; Bentall, n =126). VSRR patients were compared with 123 patients who underwent valve resuspension and root repair with postoperative echocardiograms ≥1 year.

Results: VSRR patients were younger (VSRR, 44 ± 11 years vs root repair, 55 ± 13 years; P < .001). Preoperatively, 57% of VSRR and 35% of root repair patients had moderate or more aortic insufficiency. Cardiopulmonary bypass and myocardial ischemia times were significantly longer in VSRR (P < .001). Postoperative echocardiograms with ≥1 year follow-up were analyzed in 58 VSRR patients with median follow-up of 4.8 years (interquartile range, 3-12 years) and in 123 root repair patients with median follow-up of 3.6 years (interquartile range, 3-8 years). At 10 years, VSRR patients had superior freedom from more than mild aortic insufficiency (VSRR, 91% vs root repair, 49%; P < .001). At 10 years, freedom from aortic valve replacement was equivalent (VSRR, 98% vs root repair, 92%; P = .269).

Conclusions: VSRR provides equivalent long-term valve durability as root repair in ATAAD, even in patients with moderate or severe aortic insufficiency. In select young patients who require root replacement during ATAAD repair, VSRR represents an ideal therapy.

Background: The current guidelines for the treatment of esophageal cancer recommend a multimodal approach that includes chemotherapy, targeted therapy and immunotherapy, radiation, and surgery. Despite advances in treatment, rates of treatment failure, pathologic incomplete response, tumor metastasis, and death remain unacceptably high.

Methods: This study was a narrative literature review using the terms "resectable esophageal cancer" and "multimodal therapy" to identify prospective trials of neoadjuvant radiation and chemotherapy, individually or combined with surgery, for esophageal cancer. Trials performed between 1984 and 2022 were identified and analyzed.

Clinicaltrials: gov was queried to identify ongoing studies.

Results: Twenty-one clinical studies were identified: 15 randomized controlled trials and 6 prospective nonrandomized trials. The results of the randomized trials suggest that multimodal therapy-in the form of neoadjuvant chemotherapy in combination with radiation or chemotherapy alone, followed by surgery-is associated with better rates of local disease control and partial clinical response and, potentially, longer survival than is surgery alone. Immunotherapy is an emerging option for the treatment of patients with esophageal cancer.

Conclusions: The treatment of patients with resectable esophageal cancer is rapidly evolving. Although previous treatment options have had only limited benefits for patients, significant progress has been made during last 3 decades. The results of the available studies suggest that advances in the treatment of esophageal cancer have the potential to improve survival in these patients; however, questions remain regarding mechanisms of action, patient selection, and the use of personalized approaches that are based on genetics.

Background: Bullying, harassment, and undermining behaviour has a profound detrimental effect on the multi-professional team, patient safety, and clinical outcomes. Bullying creates a poor working and training environment , increasing stress, damaging confidence, and impairing wellbeing. We sought to characterize the prevalence and nature of bullying, harassment and undermining within cardiothoracic surgery in the United Kingdom and Republic of Ireland.

Methods: A 21-question survey was sent to all members of the Society for Cardiothoracic Surgery (SCTS) in Great Britain & Ireland. Participants were asked about baseline demographics and their experience of bullying as victim or witness.

Results: The survey was sent to 1,326 SCTS members and there were 278 responses (21.0%). Most respondents were physicians (75.2%, n = 209) and most were male (58.3%, n = 162). The majority (79.1%, n = 220) had experienced or witnessed bullying in some form within the last three years (or appointment as a professional). This was experienced directly the majority of respondents (62%, n=136) and a large minority (23.6%, n = 52) had witnessed it in their workplace CONCLUSIONS: Bullying is observed or experienced by a concerning proportion of healthcare professionals working in cardiothoracic surgery. Ongoing initiatives to reduce this within British and Irish healthcare need to be strengthened to improve prevention, reporting and investigation, and support for victims and perpetrators to keep workplaces safe for teams and individuals and to facilitate the delivery of the best possible patient care.

Background: Lower mini-sternotomy offers the advantage of providing excellent visualization of the 4 cardiac cavities, allowing surgical treatment of aortic, mitral and tricuspid valves as well as any intra-cavitary procedure. Technical issues, as well as safety and echocardiographic results of this approach, are lacking. The aim of this retrospective study was to describe outcomes of lower mini-sternotomy to treat valvulopathies and other intracardiac surgeries.

Methods: All consecutive patients over 18 who underwent cardiac surgery by mini-sternotomy between January 2017 and March 2023 in our institution (Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France) were included in this retrospective study. Main outcome variables were all-cause mortality, post-operative complications and echocardiographic results.

Results: During the 6-year study period, 633 patients were treated via a lower mini-sternotomy. Among them, 338 patients had aortic valve surgery (AVS) ± tricuspid annuloplasty (TA), 254 had mitral valve surgery (MVS) ± TA, 25 had AVS + MVS ± TA and 38 had other types of intracardiac surgery. Hospital survival was 99.1% in the AVS group, 98.1% in the MVS ± TA group, 96% in the AVS + MVS ± TA group and 97.4% in the other intracardiac surgery group. Only one patient required re-osteosynthesis in the entire cohort and 12 (2.1%) patients suffered from mediastinitis. 162 (25%) patients received transfusion, 11 patients (1.7%) had permanent stroke and 49 (7.5%) had new pacemaker implantation.

Conclusions: lower mini-sternotomy is a safe approach for treating all valvulopathies, separately or concomitantly, or other intra-cardiac pathologies with a low rate of morbi-mortality.

Background: Long segmental congenital tracheal stenosis and long segmental congenital tracheobronchial stenosis are rare congenital airway anomalies with variable arborizations. This study aimed to analyze presentations and outcomes of slide tracheoplasty in long segmental congenital tracheal and tracheobronchial stenosis with variable arborizations.

Methods: Retrospective analysis included all patients who underwent slide tracheoplasty between March 1995 and February 2023 for long segmental congenital tracheal and tracheobronchial stenosis at the Great Ormond Street Hospital for Children (London, United Kingdom). Preoperative airway morphology was divided into anatomic types on the basis of the Great Ormond Street Hospital for Children morphologic classification. Preoperative, intraoperative, postoperative, and follow-up variables were analyzed and compared among patients with different arborizations with long segmental congenital tracheal and tracheobronchial stenosis.

Results: A total of 210 patients underwent slide tracheoplasty for long segmental congenital tracheal and tracheobronchial stenosis. The median age at surgery was 6 months (interquartile range, 3-15 months), and the median weight was 6.4 kg (interquartile range, 4.2-8.7 kg). Of these patients, 40% (n = 85) had abnormal arborization, and tracheobronchial morphology was the most common. A total of 24% (n = 50) patients had stenosis extending to 1 or more bronchi. Patients with carinal trifurcation presented early with critical airway stenosis, requiring ventilation support (60%) and extracorporeal membrane oxygenation support (35%) as bridge therapy to slide tracheoplasty. The duration of postoperative ventilation was higher in the patients with congenital tracheobronchial stenosis (P = .006). Patients with a morphology with trifurcation arborization had higher mortality (23%) and stent requirement (35%).

Conclusions: Slide tracheoplasty remains the standard surgery for long segmental congenital tracheal and tracheobronchial stenosis even with different arborizations. Preoperative identification of tracheal arborizations and of the extent of stenosis aids surgical strategies for better outcomes.

Background: Predicted heart mass ratio (PHMr) has become the standard donor-recipient size matching method in heart transplantation. While utilization of small PHMr hearts is associated with increased one-year mortality, the underlying mechanisms and time horizon of mortality remain uncertain.

Methods: A single institution analysis of isolated heart transplant recipients (01/2019-7/2022) was performed (N=334). Patients were stratified by PHMr: undersized (<0.86) (n=106), matched (0.86-1.15) (n=175), and oversized (>1.15) (n=53). Survival within PHMr groups was further stratified: complex transplant group (preoperative LVAD, adult congenital, or preoperative ECMO) and non-complex transplant group (all others).

Results: Donor and recipient variables were similar. However, undersized patients were more likely to have a durable LVAD (P=0.022). While postoperative PGD and inotrope score were similar between groups, there was a trend toward increased postoperative dialysis need with undersized hearts (P=0.056). Overall, thirty-day (P=0.012) and one-year survival (P=0.002) was significantly worse in the undersized group compared to matched or oversized groups. However, on subset analysis, these differences only remained among the complex transplant recipients (P=0.013), but not the non-complex transplant recipients (P=0.428). Median mixed venous oxygen saturations at serial time-points were maintained between 65-70% in all heart size groups, with cardiac indices between 2.4-2.8 LPM/m2.

Conclusions: Small PHMr hearts are associated with increased one-year mortality, driven by complex transplant operations. Recipients who received undersized PHMr hearts from non-complex transplant operations had a similar hemodynamic profile and survival as those who received matched and oversized hearts. Small PHMr hearts may be selectively safe for transplantation.