Annals of Thoracic Surgery最新文献

Background: To evaluate the progress of care for patients with Marfan syndrome with FBN1 pathogenic variant carriers, (MFS) over the past 30 years.

Methods: Patients who visited the centre were entered into a prospective registry. Aortic events (surgeries and dissections) and deaths are reported in 10-year periods (1995-2004, 2005-2014 and 2015-2023).

Results: 1,898 MFS patients were included, aged 24.90 [IQR, 10.83-39.07] years at their first visit including 51% female. Age at first visit decreased by 6 years over the 3 periods. The incidence of aortic root surgery before the first visit tended to increase [38/516 (7.4%) vs. 77/903 (8.5%) vs. 41/479 (8.6%)], and valve-sparing surgery increased at the expense of Bentall procedures. Aortic dissections occurrence decreased: (7.8% vs. 6.1% vs. 4.8%, p < 0.001). This decrease was limited to type A aortic dissections (6.0% vs 4.7% vs 2.7%, p<0.001), which mainly occurred before the first visit (87%). In contrast, the incidence of type B aortic dissections did not change: (1.7% vs. 1.4% vs. 2.1%), with 52% occurring after the first visit. Lastly, survival according to the year of first visit significantly increased (p < 0.001): with the percentage of patients who survived for 75 years increasing from 52.4%, to 63.0%, and 79.4%.

Conclusions: The incidence of type A aortic dissections decreased, valve sparing surgery is becoming the standard and survival improved. However, current care does not prevent type B dissections. These results are important for patients' information, and focusing research on remaining issues.

Dr. John Benfield was the 30th president of the Society of Thoracic Surgeons and held leadership positions in virtually every major thoracic surgical organization during his long and productive career. He was instrumental in expanding the STS Database, promoting ethics and professionalism in cardiothoracic surgery and enhancing education and mentorship programs for the future leaders of the profession.

Pulmonary metastases from sarcoma may involve central lung structures, limiting treatment options and sometimes requiring extensive resection. In this case, a 47-year-old woman with a solitary left hilar metastasis underwent pneumonectomy, ex vivo tumor resection, and reimplantation of the remaining lobe. She recovered well and remained recurrence-free at two years. This lung-preserving ex vivo resection and autotransplantation technique may offer a valuable option for select patients with centrally located pulmonary metastases in specialized centers.

Background: Several Left Ventricular Assist Device (LVAD) risk models exist however, currently there is only one LVAD available, therefore we assessed prognostic accuracy of including data from other durable LVADs vs fully magnetic devices only in 3-year survival models.

Methods: All patients receiving primary continuous flow LVADs in The Society of Thoracic Surgeons (STS) National Intermacs Database (1/2013-4/2023) were included. Patients were stratified into 3 cohorts: Cohort 1 (fully magnetic devices only, 2018-2023, n=12,449), Cohort 2 (hydrodynamic and magnetically levitated and axial flow, 2018-2023, N=3,235), and Cohort 3 (hydrodynamic and magnetically levitated and axial flow devices, 2013-2017, n=14,019). Machine learning multivariable Oblique Random Survival Forests compared 3 models predicting 3-year survival in testing sets from the fully magnetic cohort. Model 1 included only Cohort 1 patients, Model 2 included Cohorts 1 and 2, and Model 3 included Cohorts 1,2, and 3.

Results: Among patients with fully magnetic LVAD, 2,552 (20.5%) died within 3-years of implantation. Model discrimination, assessed by mean time dependent AUCs, was similar for all three models (0.706, 0.700, and 0.706) Calibration evaluated by time dependent delta Brier score demonstrated Model 1 had superior performance compared to Model 2 (p=0.016) and Model 3 (p=0.038), particularly after the first-year post-implant.

Conclusions: Models including data from older/alternative durable LVADs showed similar or inferior performance compared to a Model using fully magnetic device-only patients. These finding support current methodology including only patients receiving fully magnetic LVAD, while also providing a framework for model comparisons in future device eras.

Background: Multi-arterial grafting (MAG) is under-utilized. We evaluated the association between surgeon experience and conduit utilization outcomes following MAG.

Methods: Using US Centers for Medicare and Medicaid data, we identified 29,268 patients ≥ 65 years undergoing isolated, primary, non-emergency MAG, of which 15,682 met the inclusion criteria. Propensity score matching was performed on 26 baseline patient characteristics. Individual surgeons were grouped into tertiles based on conduit use. Low volume:<3 radial arteries or 2 bilateral internal thoracic artery (BITA) grafts annually; high-volume:>10 radial arteries or 4 BITAs annually. The primary outcome was major adverse cardiac events (MACE): death, myocardial infarction or repeat revascularization at 4-years. Outcomes were compared in a multivariable Cox-proportional hazard model adjusting for the individual surgeon's case volume of each conduit.

Results: Among MAG recipients, 5,784 (20%) received radial artery grafts and 9,989 (34%) received BITA grafts. Radial artery recipients were younger (70.6 vs. 71.2years) and more likely diabetic (46.9% vs 43.2%) than BITA recipients. Among 5,778 matched pairs, at 4-years, the incidence of MACE was numerically lower in the radial group (14.7% vs 15.7%, p=0.05), but there was no difference in all-cause mortality (10.8%radial vs 11.5%BITA, p=0.06). Among BITA recipients, surgeon experience was associated with MACE only among the lowest vs the highest volume tertile (Adjusted HR:1.15, 95%CI: 1.01=1.33, p=0.046). There was no association between MACE and surgeon volume for radial artery graft recipients.

Conclusions: Radial artery and BITA grafting demonstrated similar mid-term outcomes, while there was a surgeon volume effect for BITA use.

Robotic cardiac surgery has advanced substantially in recent years; however, its application remains limited in patients with concomitant coronary artery and valvular disease. We report two patients with severe mitral regurgitation and proximal LAD stenosis who successfully underwent robotic mitral valve repair combined with on-pump coronary artery bypass grafting to the LAD using a robotically harvested internal mammary artery. Both procedures yielded favorable outcomes. This approach demonstrates the feasibility and potential clinical utility of robotic, minimally invasive surgery in appropriately selected patients with mitral valve disease complicated by LAD lesions, expanding the therapeutic possibilities for this challenging patient population.