Annals of Thoracic Surgery最新文献

Background: Current evidence supports equipoise between surgical aortic valve replacement (AVR) and transcatheter AVR (TAVR) for the management of symptomatic severe aortic stenosis (AS). The optimal interventional management for lower-risk patients is controversial. Minimally invasive robotic AVR (RAVR) was developed as a potential option.

Methods: A total of 605 consecutive patients (2017-2023) managed by the identical structural heart team, 174 RAVR and 431 TAVR, were propensity matched and evaluated for in-hospital and 1-year outcomes.

Results: There were 288 low- to intermediate-risk (The Society of Thoracic Surgeons predicted risk of mortality <8%) patients matched in 2 well-balanced groups (144 RAVR vs 144 TAVR). In-hospital and 30-day mortality were similar. There were 2 conversions to sternotomy in the TAVR group (cardiac arrest and coronary occlusion) and none in the RAVR group. Eight RAVR patients (5.6%) required reoperation for hemothorax evacuation. TAVR was associated with higher new pacemaker (11 vs 3, P = .028) and major vascular complications (13 vs 0, P < .0001), and a higher postprocedural stroke trend (6 vs 1, P = .056). There was no difference in 30-day transfusions, atrial fibrillation, or 1-year mean valve gradients. However, 1-year mortality (12.5% vs 1.4%, P < .0001) and paravalvular leak greater than mild (32.6% vs 2.3%, P < 0.0001) were significantly higher in TAVR.

Conclusions: These data highlight lower pacemaker and vascular complications, as well as less 1-year paravalvular leak and mortality with RAVR compared with TAVR. RAVR may provide a safe and effective minimally invasive alternative to TAVR for low- and intermediate-risk patients presenting with severe symptomatic AS.

Background: Although the goal-directed perfusion (GDP) during cardiopulmonary bypass (CPB) has been discussed a lot in adult studies, no pediatric indexed oxygen delivery (DO₂i) thresholds are universally accepted, and no pediatric randomized controlled trial (RCT) is reported until now. This study aimed to determine whether the GDP initiative (maintaining DO₂i ≥ 360 mL/min/m² during CPB) could reduce the incidence of acute kidney injury (AKI) after pediatric cardiac surgery and improve clinical outcomes.

Methods: This single-center RCT enrolled 312 pediatric patients, who were randomized to receive either the GDP strategy or a conventional perfusion strategy during CPB. The primary outcome was the rate of postoperative AKI. Secondary outcomes included major postoperative complications, all-cause mortality within 30 days and short-term clinical outcomes after surgery.

Results: AKI occured in 43 patients (28.1%) in the GDP group and in 65 patients (42.2%) in the control group (relative risk, 0.67; 95% confidence interval, 0.49-0.91; P = 0.010). In the subgroup analysis, The GDP group had a lower AKI rate compared with the control group among patients with age less than 1 year, with nadir temperature greater than 32°C and nadir hemoglobin less than 8 g/L during CPB, with preoperative cyanosis, and with CPB duration from 60 to 120 minutes.

Conclusions: The GDP strategy aimed at maintaining DO₂i ≥ 360 mL/min/m² during CPB is effective in reducing the risk of AKI after pediatric cardiac surgery.

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: There are limited data concerning pneumonectomy after preoperative induction therapy. Our study aimed to evaluate feasibility and safety of pneumonectomy after neoadjuvant immunotherapy in patients with non-small cell lung cancer by assessing postoperative outcomes.

Methods: A total of 1187 patients who underwent pneumonectomy for non-small cell lung cancer were retrospectively analyzed from 3 hospitals in China. Propensity score matching was adopted to form a balanced cohort between neoadjuvant therapy and non-neoadjuvant therapy groups. Univariable and multivariable logistic regression analyses were used to identify risk factors for postoperative morbidity. Efficacy and survival were compared for neoadjuvant therapy with or without immunotherapy.

Results: The neoadjuvant group had larger tumors (4.7 ± 2.2 cm vs 3.9 ± 1.9 cm [P < .001]; cT4, 36.3% vs 19.1% [P < .001]), had a greater rate of N2 metastases (64.5% vs 33.3%; P < .001), and were at a more advanced clinical TNM stage (stage III, 89.4% vs 58.6%; P < .001). No significant difference in postoperative morbidity was observed between the groups before and after propensity score matching (43.5% vs 42.9% [P = .975]; 49.4% vs 41.9% [P = .162]). The complete pathologic response rate of neoadjuvant chemoimmunotherapy was significantly superior to that of chemotherapy alone (27.7% vs 2.0%; P < .001), and no significant difference in postoperative morbidity was observed in neoadjuvant therapy with or without immunotherapy. The neoadjuvant chemoimmunotherapy group also obtained a survival benefit with a 3-year overall survival (79.8% vs 67.5%; P = .001) and a 3-year event-free survival (63.3% vs 41.2%; P = .004).

Conclusions: After neoadjuvant therapy with immunotherapy, pneumonectomy can be safely performed in selected patients without increased postoperative morbidity.