Annals of Thoracic Surgery最新文献

Background: We implemented a preoperative screening brain magnetic resonance imaging (MRI) protocol for neonates undergoing cardiac surgery. The intent was to identify unrecognized central nervous system (CNS) injury that might alter the timing or type of surgical intervention.

Methods: This retrospective study included 397 neonates who underwent cardiac surgery with cardiopulmonary bypass between 2017 and 2025. Patients were stratified by whether they received a preoperative brain MRI (pre-MRI vs. no-MRI).

Results: Of 397 neonates, 339 (85%) received preoperative brain MRI, and 58 (15%) did not. Patients who did not receive preoperative brain MRI were more likely to present with emergent or salvage-level acuity, likely precluding the opportunity for preoperative imaging. When performed, preoperative brain MRI identified abnormal findings in 47% of cases. However, the surgical plan was altered in only two stable patients (0.6%) due to low-grade MRI findings (grade II intraventricular hemorrhage in one and trace subdural hematoma with large cephalohematoma in another). In both patients, surgery was delayed by two weeks and then proceeded uneventfully. Despite differences in acuity between groups, postoperative neurologic outcomes were similar between pre-MRI and no-MRI groups, including postoperative seizure (no-MRI: 5% vs. pre-MRI: 4%, p=0.71), stroke (2% vs. 3%, p>0.99), and cerebral hemorrhage (2% vs. 1%, p=0.53).

Conclusions: Our preoperative brain MRI screening protocol revealed that nearly half of neonates with congenital heart disease harbor abnormal findings on pre-surgical imaging. However, early identification of clinically silent brain abnormalities rarely altered the surgical plan and did not reduce the rate of postoperative CNS injury.

Background: Mechanical atrioventricular valve (AVV) replacement in single ventricle patients carries significant risks with limited outcome data. We evaluated outcomes and identified risk factors for mortality after mechanical AVV replacement during staged Fontan palliation.

Methods: We retrospectively reviewed 22 patients who underwent mechanical AVV replacement from 1997 to 2022 after completing at least stage I palliation. Patients were stratified by early postoperative ventricular function (normal vs. impaired) and timing of AVV replacement (primary vs. post-atrioventricular valve repair). The primary outcome was transplant-free survival.

Results: Median age at valve replacement was 1.7 years (interquartile range: 0.5-8.0). Hypoplastic left heart syndrome was the most common diagnosis (n=10), and the Norwood procedure was the most frequent stage I palliation (n=13). AVV replacement was performed before or at Fontan completion in 14 patients and after in 8 patients. A previous AVV repair was performed in 11 patients. Intraoperatively, 8 patients converted to AVV replacement after attempted AVV repair. There were four in-hospital deaths (18.2%). Transplant-free survival at 1 year was 55.6%. Postoperative reduced ventricular function (hazard ratio: 4.890, P=.018) and longer cardiopulmonary bypass time (hazard ratio: 1.013, P=.033) were risk factors for mortality. Patients with preserved ventricular function showed significantly better survival than those with impaired function (mild, moderate, or severe) (100% vs. 25.7% at 1 year, P<.001).

Conclusions: Approximately 1 in 10 single ventricle patients undergoing AVV surgery required mechanical AVV replacement. Outcomes are dependent on the preserved ventricular function and the results of valve repair prior to AVV replacement.

Background: To evaluate the impact of atrioventricular valve regurgitation (AVVR) onset and atrioventricular valve repair (AVVrep) on survival in single ventricle (SV) patients using the multistate model and to analyze how successful AVVrep alters clinical course.

Methods: We retrospectively reviewed all SV patients who underwent surgical palliations from 1998 to 2022, classified based on timing of AVVR onset, AVVrep, and bidirectional cavopulmonary shunt (BCPS). AVVrep was defined as successful if patients remained free from AVVR, death, or heart transplant (HTx) for at least one year post-repair. Clinical trajectories were analyzed using a multistate model incorporating time-dependent variables. Transplant-free survival was estimated using Kaplan-Meier and competing risk analyses.

Results: Among 716 SV patients, 195 developed AVVR and 155 underwent AVVrep. Of these, 69 had a successful repair. Successful AVVrep significantly reduced risk of death/HTx (HR 0.16[95%CI 0.07,0.40], p<0.001), achieving survival comparable to patients without AVVR(p=0.94). In patients with AVVR onset before BCPS, reduction in the risk of death/HTx could be achievable if those requiring AVVrep before BCPS reached BCPS(HR 0.18[0.05,0.65], p=0.009) and when AVVrep was performed at or after BCPS(HR0.24[0.11,0.53], p<0.001). Ventricular dysfunction, whether primary or secondary to AVVR, was strongly associated with inferior survival.

Conclusions: Successful AVVrep potentially reduces risk of death/HTx by 84% in SV patients with AVVR onset, particularly when performed at or after BCPS, resulting in comparable survival to those with no AVVR. Early AVVrep before BCPS confers high risk unless AVVrep is successful. Timing and success of AVVrep are critical determinants of long-term survival.

Background: The choice between bioprosthetic or mechanical surgical aortic valve replacement (SAVR) for dialysis patients is debated. Rapid adoption of transcatheter aortic valve replacement (TAVR) complicates decision-making further. This study compared AVR prosthesis choices among dialysis patients.

Methods: Dialysis patients who underwent bioprosthetic AVR (bAVR), mechanical AVR (mAVR), and TAVR from 2009 to 2019 were queried from MedPAR data. Two propensity score matches were performed: bAVR versus mAVR and SAVR (bAVR + mAVR) versus TAVR. Five-year survival was compared using restricted mean survival time (RMST). Secondary outcomes were compared using subhazard regression with death as a competing risk.

Results: 2,590 patients underwent mAVR, 4,752 bAVR, and 7,739 TAVR; respectively, mean ages were 61.5, 66.6, and 73.2 years. Matching mAVR and bAVR yielded 2,460 patients each. Survival was similar with RMST of 2.67 years for mAVR and 2.60 years for bAVR (Difference = -0.07, P=0.170). For mAVR, gastrointestinal bleeding readmission was higher (32.7% vs 28.6%, P=0.002) while reoperation was lower (3.6 vs. 5.8%, P<0.001). Matching SAVR and TAVR yielded 2,709 patients each. SAVR had worse early but improved 5-year survival, RMST 2.43 versus 2.18 years (Difference = -0.25, P<0.001). Readmissions for gastrointestinal bleeding (∼31%) and reoperation (∼3%) were similar.

Conclusions: Dialysis patients undergoing SAVR and TAVR have poor survival, high bleeding risk, and low reoperation rate regardless of prosthesis choice. Our data suggests no difference in five-year overall survival between bAVR and mAVR, while SAVR was associated with worse early but improved five-year overall survival compared to TAVR.

Purpose: Tetralogy of Fallot with absent pulmonary valve (TOF-APV) can present neonatally with severe respiratory insufficiency due to tracheobronchomalacia (TBM). Typical treatment of TOF/APV patients with significant respiratory compromise are directed at the underlying heart defect rather than the airway. Complete repair often does not ameliorate airway issues and subsequently requires tracheostomy/ventilator.

Description: Due to this lack of effective treatment, a bioresorbable, patient-specific, 3D-printed splint was developed, which provides external support to the airways.

Evaluation: Eight patients with TOF-APV and TBM underwent airway splinting. Cohort 1 underwent splinting after (n=5) or concurrently (n=1) with a complete repair with right ventricle-to-pulmonary artery conduit. Cohort 2 underwent splinting prior to a complete repair (n=2). All Cohort 1 subjects required tracheostomy and long-term ventilator support. The Cohort 2 subjects were discharged home after splinting and returned to undergo elective TOF repair without conduit.

Conclusions: Patients with TOF-APV and airway compromise may avoid early repair with conduit and tracheostomy with initial airway splinting. They are then able to undergo elective TOF repair without conduit.

Background: Post-cardiotomy acute right ventricular failure (aRVF) constitutes a complex clinical challenge that might necessitate escalating interventions, including extracorporeal life support (ECLS). This study evaluates outcomes of adults requiring ECLS for post-cardiotomy acute right ventricular failure (aRVF) compared to other post-cardiotomy indications.

Methods: In this multicenter, international, retrospective study, we analyzed patients undergoing post-cardiotomy ECLS from January 2000 to December 2020 and compared patients' characteristics and in-hospital mortality between aRVF and other indications groups.

Results: Of 2010 patients, 240 (12%) had aRVF and 1770 (88%) had other indication for ECLS. Demographics were similar between groups (median age: 65 years [55-72]; p=0.217; males 60%; p=0.675). The aRVF group showed higher pre-operative right-sided cardiac dysfunction, including pre-existing right ventricular failure (aRVF: 22%; other indications: 8%; p<0.001) and biventricular failure (aRVF: 12%; other indications: 7%; p=0.013). aRVF patients more frequently underwent tricuspid valve surgery (aRVF: 20%; other indications: 13%; p=0.003) and aortic root procedures (aRVF: 24%; other indications: 13%). They also required longer ECLS support (aRVF: 135 hours [70-221]; other indications:116 hours [58-192]; p=0.025) and longer intensive care unit stay (aRVF: 15 days [7-291]; other indications: 13 days [6-25]; p=0.042). Despite more complications, including non-surgical bleeding (aRVF: 31%; other indications: 25%; p=0.042) and persistent right heart failure (aRVF: 50%; other indications: 17%; p<0.001), both in-hospital survival (aRVF: 59%; other indications: 61%; p=0.526) and long-term survival were comparable (log-rank p=0.17).

Conclusions: Patients requiring ECLS for post-cardiotomy aRVF, despite higher pre-operative risks and complex clinical courses, achieve survival rates comparable to other indications patients.

Background: As with hypoattenuated leaflet thickening observed early after transcatheter aortic valve replacement, early cusp thickening and reduced cusp motion after the Ozaki procedure sometimes occurs.

Methods: From 2014 to 2016, 184 patients underwent Ozaki procedures at Toho University Ohashi Medical Center, of whom 143 had adequate quality transesophageal echocardiography (TEE) within 2 weeks postoperatively. Cusp thickening was defined as new hyperechoic meniscal appearance compared with the intraoperative TEE. We investigated frequency of cusp thickening and reduced cusp motion and their effect on longitudinal valve performance and clinical outcomes during the subsequent median 5.9-year follow-up.

Results: Of the 143 patients, 32 (22%) developed early cusp thickening and 57 (40%) reduced cusp motion. Neither resulted in escalation of antithrombotic therapy. All patients with cusp thickening had reduced cusp motion. Smaller aortic sinus size and higher low-density lipoprotein cholesterol levels were associated with occurrence of cusp thickening and cusp size difference with occurrence of reduced cusp motion. There was no difference in risk of all-cause mortality or aortic valve reoperation between patients with and without cusp thickening (P=.44 for both), and cusp thickening was not associated with higher mean gradients (P=.39).

Conclusions: Without escalation of antithrombotic treatment, mid-term outcomes of patients with early cusp thickening or reduced cusp motion were comparable to those without. This phenomenon is frequent, and although it appears benign, concern remains and requires further studies.