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.

Background: Physician modified fenestrated and branched endografts (PMEGs) have emerged as an endovascular solution for managing thoraco-abdominal aortic aneurysms (TAAAs) in the past decade. This study aimed to evaluate the outcomes and experience of three high- volume centers.

Methods: Patients' data from three academic center in China, spanning from 2017 and 2021, were retrospectively collected and analyzed. Early outcomes were assessed through peri-operative morbidity and mortality. Follow-up outcomes included survival, freedom from reintervention, and target vessels patency.

Results: A total of 186 patients (156 males; mean age 68.4 ± 13.4 years) with TAAAs underwent PMEG procedures. A total of 618 target vessels were incorporated via fenestrations or branches. Postoperative all-cause was 6.5%, with aneurysm-related deaths accounting for 1.6%. Morbidity included acute kidney injury (5.9%), stroke (1.1%), myocardial infarction (2.7%), and limb ischemia, respiratory failure, and bowel ischemia requiring resection (each 1.6%). One patient developed transient spinal cord injury. With a mean follow-up of 3.4±1.3 years, 1-and 3-year survival rates were 96% and 94%, respectively. The 1-and 3-year secondary patency rates of target vessels were 99% and 98%, while freedom from reintervention rate were 95% and 91%.

Conclusions: Fenestrated and branched endovascular aneurysm repair with PMEGs appears to be a safe and effective treatment for complex aortic aneurysms. While early and mid-term outcomes are promising and comparable to those of custom-made devices, further follow-up is essential to confirm long-term efficacy.

Background: Retrospective studies of patients with ischemic mitral regurgitation(iMR) undergoing coronary artery bypass grafting(CABG) with concomitant mitral valve surgery frequently report improved survival with mitral valve annuloplasty(MVr) over replacement(MVR). However, the only randomized controlled trial found no survival difference.

Methods: Medicare claims data were queried to identify beneficiaries with iMR undergoing CABG+MVr or CABG+MVR. Kaplan-Meier estimates of survival after CABG+MVr and CABG+MVR were generated, and 20-year restricted mean survival times(RMST) were compared. Then, surgeons were stratified by their rate of CABG/MVr into groups with a demonstrated preference for MVr(PA) or MVR(PR). Outcomes were re-analyzed by surgeon preference. Overlap propensity score weighting was used for risk-adjustment in all analyses.

Results: Among 10,471 beneficiaries with iMR, 6,457(61.7%) underwent CABG+MVr and 4,014(38.3%) underwent CABG+MVR. Risk-adjusted RMSTs were 6.02[5.77,6.26] versus 5.57[5.33,5.81] years after CABG+MVr and CABG+MVR, respectively(difference 5.4[1.2,9.4] months, p=0.01). Among 1,118 surgeons, 223 PA(performed 2,191 surgeries; 89.5% MVr rate) and 235 PR(performed 1,930 surgeries; 23.0% MVr rate). Risk-adjusted RMSTs were 5.76[5.36,6.15] versus 5.77[5.40,6.14] years among beneficiaries undergoing surgery by PA surgeons and PR surgeons, respectively(difference 0.1[-6.6,6.6] months, p=0.964).

Conclusions: In Medicare beneficiaries with iMR undergoing CABG+MVS, CABG+MVr was associated with improved survival, even after risk-adjustment for measured confounders. This may be due to unmeasured confounding variables affecting the decision to perform MVr or MVR, such as valvular pathology and/or severity of regurgitation. After endeavoring to account for unmeasured confounders using surgeon preference as an instrumental variable, surgeons who preferred CABG+MVr or CABG+MVR achieved similar long-term survival for their patients.

Background: Guidelines for treating ascending thoracic aortic aneurysms (ATAA) are largely based on single-center studies. To understand factors influencing patient selection for surgery versus surveillance, patient and aneurysm characteristics were compared for subjects in the randomized and registry arms of a large prospective, multi-center, multi-national trial.

Methods: TITAN: SvS (Treatment in Thoracic Aortic aNeurysm: Surgery versus Surveillance) is the largest prospective multi-center study of patients with ATAA between 5.0-5.4 cm, randomizing patients 1:1 to initial surgery versus surveillance. Non-randomized patients are enrolled into a Registry where results of operative or surveillance strategy can be followed prospectively. Between 2018 and 2023, 615 patients were enrolled at 22 sites in USA and Canada. Demographic and aneurysm characteristics were compared between randomized and registry arms.

Results: Compared to randomized and operative registry groups, patients in the surveillance registry were older with more co-morbidities. No significant differences were observed in maximal ascending aortic diameter [(5.1 (5.0, 5.2) vs 5.1 (4.9, 5.2) cm, p=0.2] or other aneurysm characteristics. Despite similar numbers of enrolling centers in the USA (n=11) and Canada (n=12), Canadian patients were more likely to be randomized (58% vs. 7%, p<0.01), and less likely to be enrolled in the operative (9% vs. 42%, p <0.01) or surveillance registry (34% vs. 51%).

Conclusions: Enrollment data TITAN:SvS suggests that patient and geographic characteristics, rather than aortic size, influence decision-making regarding the initial treatment strategy for ATAAs. These findings highlight the need for caution when generalizing outcomes from operative registries, as sicker patients may be excluded.