Annals of Thoracic Surgery最新文献

Background: Acute renal failure remains a significant complication after open thoracoabdominal aortic aneurysm (TAAA) repair and is associated with high mortality. Rigorous risk estimation for this complication is vital for these patients.

Methods: Data were analyzed from 2809 patients who underwent elective, open TAAA repair between 1986 and 2024 at a single practice. Persistent renal failure was defined as the need for dialysis at time of operative discharge (including any hospital transfer) or death. The effectiveness of 4 predictive models-multivariable logistic regression, random forest, support vector machine, and gradient boosting machine-was compared by using the test C-statistic (C) from an 80:20, 1000-iteration cross-validation scheme. The regression model was converted into a nomogram for patient counseling.

Results: Persistent renal failure necessitating dialysis developed in 158 (5.6%) patients, of whom 90 (57.0%) experienced operative death. Of the 4 models, the regression model was the most predictive (C=0.75 [0.72-0.77]). The highest-performing machine learning model, the gradient boosting machine, had similar efficacy (C=0.73 [0.70-0.76]). The final regression model included 8 factors: Crawford extent II repair (odds ratio [OR]=1.86, P=.001), chronic aortic dissection (OR=1.72; P=.01), symptomatic aneurysm (OR=1.47, P=.03), maximum distal aortic diameter ≥6 cm (OR=1.44, P=.06), age (OR=1.04; P<.001), preoperative estimated glomerular filtration rate (OR=0.97, P<.001), male sex (OR=0.65, P=.01), and Crawford extent I repair (OR=0.43; P=.004).

Conclusions: The regression model, built using preoperative factors, effectively predicted persistent renal failure necessitating dialysis in patients undergoing elective, open TAAA repair. We converted this model into a nomogram to aid in preoperative counseling.

Background: The Society of Thoracic Surgeons (STS) 2023 Guidelines for the Surgical Treatment of Atrial Fibrillation (AF) established concomitant surgical ablation (SA) and left atrial appendage occlusion (LAAO) as class I recommendations. This study uses the STS Adult Cardiac Surgery Database (STS-ACSD) to quantify trends in adherence.

Methods: Patients undergoing primary coronary artery bypass grafting (CABG), aortic valve surgery (AVRr), and/or mitral valve surgery (MVRr) from July 2017 through December 2023 were analyzed. Data were analyzed for frequency trends for SA and LAAO in all patients with preoperative AF and stratified by surgical sub-cohorts (isolated CABG, AVRr±CABG, or MVRr±CABG). Variability in rates of SA and LAAO was also analyzed by patient characteristics, surgeon, program, and geographic region.

Results: The study included 1,242,607 patients, of whom 11.8% had preoperative AF. During the study period, the rate of no AF treatment decreased from 42.4% to 24.8%, while the rate of isolated LAAO increased from 14.7% to 30.1%. The rate of any SA remained stagnant at around 45%. Patients with medical comorbidities and those undergoing non-elective surgery, isolated CABG, or surgery in the Mid-Atlantic region were less likely to receive surgical AF treatment, especially SA. AF treatment by surgeon was highly variable, and program volume of cases with preoperative AF was correlated with rate of surgical treatment for AF.

Conclusions: Despite increasing application of surgical treatment of preoperative AF in the U.S., variability and undertreatment persist. Concerted efforts at education, monitoring adoption, and the potential establishment of quality metrics should be considered.

The optimal extent of resection for early-stage non-small cell lung cancer (NSCLC) remains one of the most debated questions in thoracic surgery. While lobectomy has traditionally represented the standard of care, contemporary randomized trials have redefined the role of sublobar resection. For appropriately selected patients with small, peripherally located tumors, segmentectomy has shown oncologic equivalence to lobectomy¹, whereas the evidence supporting wedge resection remains less definitive². This review synthesizes the available evidence comparing wedge resection and segmentectomy, contextualized against lobectomy as the historical benchmark. A comprehensive literature review was performed, focusing on studies published over the last 30 years reporting outcomes of anatomic and non-anatomic, lobar and sublobar lung resections in patients with stage I NSCLC. Wedge resection offers a less invasive option for early-stage NSCLC, with potential benefits in pulmonary preservation and perioperative safety. However, current evidence remains mixed, and while wedge resection may be appropriate in carefully selected standard-risk patients, its routine use awaits further high-level validation. Careful patient selection, attention to margins, appropriate lymph node evaluation, genetic and consideration of tumor biology are critical in determining patients for whom a wedge resection can be oncologically adequate.

Background: Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) is a complex and heterogeneous form of congenital heart DISEASE: The purpose of this manuscript is to provide a 20-year perspective on the lessons learned and related advancements in unifocalization of MAPCAs and pulmonary arteries.

Methods: The author of this manuscript provides his unapologetically Stanford-centric perspective on the most salient advances in treatment of PA/VSD/MAPCAs.

Results: There have been a multitude of advances in the treatment of PA/VSD/MAPCAs over the past 20 years. Some of these advances have occurred in surgical techniques for performing unifocalization and unifocalization revision. There have also been significant advances in the non-surgical aspects of care. Cumulatively and incrementally, these advances have resulted in better and better results over time. Dissemination of this knowledge and information has been an important step in a more widespread understanding of these techniques and results. Finally, the improvements in results for unifocalization of MAPCAs and pulmonary arteries have further widened the gap compared to the pulmonary artery rehabilitation approach and thus what was once a controversy is now largely settled.

Conclusions: Unifocalization of MAPCAs and pulmonary arteries has undergone numerous refinements over the past 20 years. It is now clear that this is the procedure of choice for patients with single supply MAPCAs.

Background: Current guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) for patients age ≤65 years. Recent state-specific data suggest over 50% of patients age ≤65 years undergo TAVR. Given recent data of a potential survival benefit for mechanical SAVR in patients aged 60 years and younger, we sought to evaluate the national incidence of TAVR, bioprosthetic SAVR, and mechanical SAVR in young patients.

Methods: Using the PREMIER Health Database, all patients aged 40-65 years undergoing isolated AVR (2016-2024) were assessed. PREMIER is a nationally representative all-payer, all-age, inpatient and outpatient database accounting for 25% of United States population. Diagnosis-related group and International Classification of Diseases 10th revision procedure codes were used to define procedures and comorbidities and a validated frailty metric.

Results: A total of 18,694 patients receiving first-time isolated aortic valve replacement were analyzed (31.3% TAVR, 68.7% SAVR). Patients receiving TAVR were older, female, black with higher Kim frailty index (p < 0.0001). Young patients were more likely to receive TAVR at teaching hospitals and larger centers (>499 beds). TAVR increased from the beginning of the study period to a peak of 40.8% in 2020 followed by a decrease to 32.5% in 2024. Overall utilization of mechanical SAVR remained between 15-18% throughout.

Conclusions: Nearly one third of patients aged 40-65 years receive TAVR in contemporary practice. Real time data highlight that evolving TAVR use outside of current guidelines is less that previously reported in regional datasets.

Redo surgical Aortic Valve Replacement (AVR) should be favored over Transcatheter Aortic Valve Replacement (TAVR), especially in patients who have prosthetic aortic valves that cannot be fractured in whom implantation of a small sized TAVR would lead to patient prosthetic mismatch; adversely affecting the quality of life.