Annals of Thoracic Surgery最新文献

Background: In 2007, Cancer Care Ontario created Thoracic Surgical Oncology Standards for the delivery of surgery, including lobectomy, esophagectomy, and pneumonectomy. These standards regionalized thoracic surgery into designated centers and mandated physical and human resources. This analysis sought to identify the impact of these standards, hereafter referred to as "regionalization," on outcomes after thoracic oncology surgery in Ontario, Canada.

Methods: This study was a population-level analysis of patients undergoing lobectomy, esophagectomy, or pneumonectomy, and it used multilevel regression models to compare 30- and 90-day mortality and length of stay before, during, and after regionalization. Interrupted time series models were used to assess for an impact of regionalization while controlling for ongoing trends.

Results: A total of 22,195 surgical procedures (14,902 lobectomies, 4958 esophagectomies, and 2408 pneumonectomies) were performed within the study period. A total of >99% of cases were performed at a designated center after regionalization. Mean annual volumes per designated center increased after regionalization for lobectomy and esophagectomy and decreased for pneumonectomy. The 30- and 90-day mortality and length of stay improved for lobectomy and esophagectomy over the study period, as did 90-day mortality for pneumonectomy. However, the interrupted time series analysis did not demonstrate any statistically significant effect of regionalization on these outcomes, separate from preexisting trends.

Conclusions: Consistent improvements in mortality and length of stay in thoracic surgical oncology occurred on a provincial level between 2003 and 2020, although this analysis does not attribute these improvements to implementation of Thoracic Surgical Oncology Standards including regionalization.

Background: Failure to rescue (FTR) is mortality after at least 1 postoperative complication. We investigated the impact of nighttime intensivist staffing and FTR after cardiac surgery.

Methods: We included patients who underwent cardiac surgery to examine FTR, defined as mortality in those who experienced a Society of Thoracic Surgeons-defined major complication. Era 2 (July 2021-June 2023) and era 1 (July 2016-June 2021) were characterized by the presence and absence of nighttime intensivists staffing, respectively. Complications and FTR rates, daily intensive care unit (ICU) census, and relative value units (RVUs) were compared.

Results: Among 5654 patients, 17% (284 of 1661) in era 2 had at least 1 complication vs 19% (769 of 3993) in era 1 (P = .057). Among patients with complications, FTR incidence was 8% (22 of 284) in era 2 vs 19% (145 of 769) in era 1 (P < .001). The daily average ICU census did not change (12.3 in era 2 vs 12.0 in era 1, P = .386). Comparing mean annual RVUs during the 2 fiscal years in era 2 (35,613 per year) with what would have been expected based on the last 2 fiscal years of era 1 (26,744 per year), a significant increase of +8870 per year was observed (95% CI, 3876-13,863, P = .028). Multivariable analyses found no difference in the risk of major complications comparing era 2 vs era 1 (odds ratio, 1.04; 95% CI, 0.89-1.23; P = .602), and a 59% reduction in FTR risk in era 2 vs era 1 (odds ratio, 0.41; 95% CI, 0.25-0.67; P < .001).

Conclusions: Nighttime ICU coverage reduced FTR rates in postcardiotomy patients while complication rates and ICU census remained stable. Furthermore, the increase in RVUs suggested an economically sustainable model.

Background: Surgical outcomes have been linked to the technical and cognitive abilities of an exhausted surgical team. In parallel, advancements in preservation have led to the proposal of daytime lung transplants. We sought to investigate whether time of day is associated with outcomes in lung transplants.

Methods: Data on 30,404 lung transplants from 2005 to 2021 were obtained from the United Network for Organ Sharing database. Patients were categorized based on the time of surgery with early-hours defined as donor cross-clamp between 10 pm and 3 am, and Cox regression models for 90-day and long-term mortality were made to assess the risk according to time of transplant and covariates. Additionally, the Cox modeling was repeated with donor cross-clamp and the estimated reperfusion time of day as continuous functions.

Results: Among 30,404 transplants, 20.7% (6295) were performed during early hours. No significant difference was found between the 2 groups in unadjusted 90-day and long-term mortality (log-rank, P = .176 and .363, respectively), and results were unchanged when adjusting for covariates (P = .233 and .738, respectively). However, when examining donor cross-clamp time and reperfusion time as continuous variables in separate multivariable analyses, we observed significant associations with 90-day mortality (P = .002 and .022, respectively). Notably, lower mortality rates were observed for donor clamp-times between 8 am and 1 pm and estimated reperfusion times between 1 pm and 6 pm.

Conclusions: Although binary categorizations of the time of day of lung transplants did not show a significant impact on short- or long-term survival, continuous-time analyses demonstrated that certain times during the day were associated with favorable short-term survival.

Background: Children who undergo cardiac surgery may require postcardiotomy extracorporeal membrane oxygenation (ECMO). Although morbidities are considerable, our understanding of outcome determinants is limited. We evaluated associations between patient and perioperative factors with outcomes.

Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried for patients aged <18 years old who underwent postcardiotomy ECMO from January 2016 through June 2021. The primary outcome was survival to hospital discharge. The secondary outcome was survival without neurologic injury. Logistic regression for binary outcomes and competing risk analysis for survival were used to identify the most important predictors. Variables were selected by stepwise procedure using entry level P = .35. Those with P ≤ .1 were kept in the final model.

Results: Postcardiotomy ECMO was used to support 3181 patients during the same hospitalization as cardiac surgery: (A) intraoperative initiation of ECMO, n = 1206; (B) early postoperative (≤48 hours), n = 936; and (C) late postoperative (>48 hours), n = 1039. The most common primary procedure of the index operation was the Norwood procedure. Of those with intraoperative ECMO, 57% survived to discharge vs 59% with early postoperative ECMO and 42% late postoperative ECMO (χ²₍₂₎ = 64, P < .0001, V = 0.14). In all groups, postoperative septicemia, cardiac arrest, and new neurologic injury had the strongest association with mortality, whereas postoperative reintubation and unplanned noncardiac reoperation were associated with higher survival.

Conclusions: Multiple risk factors impact survival in children who undergo cardiac surgery and postcardiotomy ECMO. ECMO initiated >48 hours after surgery is associated with the poorest outcomes. This is the first step in creating a predictive tool to educate clinicians and families regarding expectations in this high-risk population.

Background: It has long been held that the safe duration of hypothermic circulatory arrest (HCA) is at least 25 to 30 minutes. However, this belief is based primarily on clinical outcomes research and has not been systematically investigated using more sensitive brain imaging and neurocognitive assessments.

Methods: This exploratory substudy of the randomized Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest (GOT ICE) trial, which compared outcomes for deep vs moderate hypothermia during aortic arch surgery, investigated the frequency of neurocognitive and structural and functional magnetic resonance imaging (MRI) deficits with HCA of short (<20 minutes) duration. Neurocognitive deficit was defined as ≥1 SD decline in ≥1 of 5 cognitive domains on neurocognitive testing.

Results: Of 228 GOT ICE participants with complete 4-week cognitive data, 74.6% (n = 170 of 228) had HCA durations <20 minutes, including 59 patients randomized to deep hypothermia (<20.0 °C), 55 patients randomized to low-moderate (20.1-24.0 °C) hypothermia, and 56 randomized to high-moderate (24.1-28.0 °C) hypothermia. Of these participants, cognitive deficit was detected 4 weeks postoperatively in ∼40% of patients in all 3 groups (deep hypothermia, 22 of 59 [37.3%]; low-moderate hypothermia, 23 of 55 [41.8%]; and high-moderate hypothermia, 24 of 56 [42.9%]). Furthermore, in a subset of patients with complete MRI data (n = 43), baseline to 4-week postoperative right frontal lobe functional connectivity change was inversely associated with HCA duration (range, 8-17 minutes; P for familywise error rate < .01).

Conclusions: Even short durations of HCA result in cognitive deficits in ∼40% of patients, independent of systemic hypothermia temperature. HCA duration was inversely associated with frontal lobe functional MRI connectivity, a finding suggesting that this brain region may be preferentially sensitive to HCA. Surgeons should be aware that even short durations of HCA may not provide complete neuroprotection after aortic arch surgery.