Annals of Thoracic Surgery最新文献

Background: Surgical ablation(SA) at the time of isolated mitral valve surgery(MVS) is recommended in patients with preexisting atrial fibrillation(AF). However, SA remains infrequently utilized during MVS with a poorly quantified impact on stroke and survival.

Methods: Medicare claims(2008-2019) were queried to identify beneficiaries with preexisting AF undergoing MVS. All-cause mortality and the post-operative incidence of stroke/transient ischemic attack(TIA) were evaluated as separate endpoints. Overlap propensity score weighting was used to risk-adjust for measured confounding variables. Analyses were repeated using surgeon frequency of SA as an instrumental variable to adjust for unmeasured confounding variables.

Results: From 2008-2019, 41,795 Medicare beneficiaries with a preexisting diagnosis of AF underwent MVS. Surgeons were categorized, with 1,326 infrequently(bottom quartile) performing SA(<30%; 10,364 beneficiaries) and 740 frequently(top quartile) performing SA(≥62%; 10,476 beneficiaries) during MVS. Beneficiaries undergoing MVS with SA("as-treated" analysis) had a risk-adjusted median survival advantage of 0.56[0.33-0.81] years (8.85[8.64-9.04] vs 8.29[8.11-8.47] years, P<0.001 for risk-adjusted survival comparison) compared to those without. Beneficiaries undergoing MVS by frequent SA surgeons("surgeon-preference" analysis) had a risk-adjusted median survival advantage of 0.35[0.05-0.71] years (8.59[8.40-8.85] vs 8.24[7.97-8.40] years, P=0.0015 for risk-adjusted survival comparison) compared to surgeons who infrequently performed SA.

Conclusions: In Medicare beneficiaries with preexisting AF, concomitant SA during MVS is associated with improved survival, as is undergoing surgery by a frequent SA surgeon. When analyzed based on surgeon preference for SA, the magnitude and time-dependent nature of the treatment effect of SA were substantially different compared to the "as-treated" analysis, suggesting that "as-treated" analyses may be subject to bias from unmeasured confounding variables.

Background: Non-ST elevation myocardial infarction (NSTEMI) patients benefit from revascularization, but guidelines are vague regarding optimal timing. We aimed to identify the ideal timing of coronary artery bypass grafting (CABG) after NSTEMI.

Methods: We examined NSTEMI patients who underwent isolated CABG within 30 days of cardiac catheterization between July 2011-July 2023 using a multicenter regional collaborative. Patients were stratified into three groups: <2 days, 3-7 days, and 8-30 days. Multivariable logistic regression analysis was performed to identify risk factors associated with mortality.

Results: We identified 10,271 CABG patients, of which 3,464 (34%) underwent CABG within <2 days, 5,751 (56%) 3-7 days, and 1056 (10%) 8-30 days. The 3-7 day group had the lowest median Society of Thoracic Surgeons predicted risk of mortality (1.36% vs. 1.35% vs. 2.09%, p<0.001). The <2 day group more frequently presented with left main disease (19% vs. 16% vs. 16%, p<0.001) and cardiogenic shock (5.1% vs. 1.8% vs. 2%, p<0.001). Mean cardiopulmonary bypass time was similar between groups (97 mins vs 97 vs 97, p=0.63). The 3-7 day group had the lowest operative mortality (3.2% vs. 1.8% vs. 4%, p<0.001) and major morbidity (14% vs 11% vs. 16%, p<0.001). After risk-adjustment, the 3-7 day window was associated with decreased mortality compared to <2 days (OR 0.56, 95%CI 0.4-0.78, p<0.001) and 8-30 days (OR 0.51, 95%CI 0.32-0.81, p<0.001).

Conclusions: CABG between 3-7 days after cardiac catheterization for NSTEMI was associated with the lowest risk of mortality. When possible, CABG within this window may afford better outcomes.

Background: Patients with endocarditis frequently require valve surgery, and despite recent growth of minimally invasive cardiac surgery (MICS) for complex valve operations, consensus recommendations still suggest conventional sternotomy.

Methods: Institutional Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database evaluated all patients undergoing valve surgery for endocarditis (1/2016-3/2024). Patients were stratified by conventional sternotomy vs MICS approach, including hemi-sternotomy, right -thoracotomy, and robotic-assisted mitral/tricuspid/aortic valve surgery. Logistic regression assessed risk-adjusted association with the primary outcomes of STS major morbidity or mortality and MICS approach accounting for all covariates in current STS risk models.

Results: Of 741 patients undergoing valve surgery for endocarditis, median age 37 years, 582 (78.5%) had substance use disorder, 210 (28.3%) redo sternotomies and 166 (22.4%) redo valve operations. MICS was associated with a higher repair rate for mitral valves (76.3% vs 48%, p<0.0001) but lower for tricuspid valve (22.5% vs 44.1%, p<0.0001), with no difference for aortic valves (8.3% vs 7.4%, p=0.372). Prior to risk adjustment, MICS was associated with longer cross clamp times (99 min vs 86 min, p=0.019) but lower incidence of STS major morbidity or mortality (15.4% vs 27.8%, p=0.019). After robust risk adjustment, age (OR 1.1, p=0.008), lung disease (OR 2.2, p=0.010), preoperative creatinine (OR 1.3, p=0.016), valve repair vs replacement (OR 0.17, p=0.002), but not MICS (OR 1.2, p=0.807) were independently associated with STS major morbidity and mortality.

Conclusions: MICS valve surgery for endocarditis appears both safe and effective, with similar repair rates and risk adjusted outcomes to open surgery.