Annals of Thoracic Surgery最新文献

In this case report, we describe an unusual presentation of gout, manifesting as a fluorodeoxyglucose-avid anterior mediastinal mass mimicking a malignant neoplasm on positron emission tomography/computed tomography. The unusual observation of tophaceous gout in the anterior mediastinum is of relevance to chest physicians and surgeons as well as to radiologists and pathologists evaluating patients with lesions in the mediastinum.

Aortic stenosis, the most common valvular disease in the Western world, has traditionally been treated with surgical aortic valve replacement (SAVR) but is increasingly treated by transcatheter aortic valve replacement (TAVR). Whereas patients older than 65 years are preferably treated with bioprosthetic tissue valves, there is considerable uncertainty in the choice between TAVR and SAVR. We present various considerations for optimizing the lifelong management of patients receiving bioprosthetic valves (SAVR or TAVR). To maximize life expectancy and to minimize cumulative lifetime risk, we suggest decision-making individualized for patient anatomy and overall (current and future) risk.

Background: The newest Commission on Cancer standards recommend sampling 3 mediastinal and 1 hilar lymph node stations, 3 (N2) 1 (N1), for lung cancer resections. However, the relationship between the Commission on Cancer standards and outcomes has not been thoroughly investigated.

Methods: A prospective institutional database was queried for clinical stage I-III lung resections before the implementation of the new standards. The relationship between the 3 (N2) 1 (N1) standard ("guideline concordant") and outcomes (upstaging, complications, receipt of adjuvant therapy, locoregional/distant recurrence, and survival) was assessed with multivariable models and stratified by stage.

Results: Of 9289 pulmonary resections, 3048 (33%) were guideline concordant and 6241 (67%) were not. Compared with nonconcordant, those that were guideline concordant had higher rates of nodal upstaging (21% vs 13%; odds ratio [OR], 1.32 [95% CI, 1.14-1.51]; P < .001) and in-hospital complications (34% vs 27%; OR, 1.17 [95% CI, 1.05-1.30]; P = .004) but similar adjuvant systemic therapy administration (19% vs 13%; OR, 1.09 [95% CI, 0.95-1.24]; P = .2; 98% chemotherapy). Locoregional and distant recurrences were not significantly improved with guideline concordance across clinical stage I, II, and III subsets. Overall survival was similar in clinical stages I and II, but improved survival was observed for guideline concordant clinical stage III patients (hazard ratio, 0.85 [95% CI, 0.74-0.97]; P = .02).

Conclusions: Sampling 3 (N2) 1 (N1) was associated with increased upstaging and complications but not with decreased recurrence or mortality in clinical stage I or II patients. Survival was improved for concordant, clinical stage III patients. Further study is indicated to determine the ideal lymph node sampling strategy across heterogeneous lung cancer patients.

Harvey W. Bender Jr spent his early years in Humble, Texas. After attending Baylor University College of Medicine, he trained in surgery at the Johns Hopkins Hospital. In 1971 he was recruited to Vanderbilt University to reinvigorate the residency training program and significantly expand the clinical services. He became Chair of the Residency Review Committee for Thoracic Surgery and of the American Board of Thoracic Surgery. He was also Chair of the Board of Regents, President of the American College of Surgeons, and President of the Southern Thoracic Surgical Association. He was a unique person whose influence will last for generations.

Background: This study describes in detail the clinical burden of malperfusion associated with acute Type A aortic dissection (ATAAD) in a large, national cohort and the effect of treatment strategy on outcomes.

Methods: All patients undergoing repair of ATAAD between 2017 and 2020 in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database were studied. Malperfusion was defined using STS definitions based on imaging or surgeon's evaluation. Multivariable logistic regression was used to analyze the effect of patient and treatment factors on outcomes in patients with and without malperfusion.

Results: A total of 9,958 patients undergoing ATAAD repair were studied. Preoperative malperfusion occurred in 27.7% (2,748/9,958) of cases and most often involved the extremity (14.9%, 1,484/9,958), renal (10.2%), or cerebral (9.8%) vascular beds. Operative mortality was much greater among malperfusion patients (26.8% vs 13.6%, P<0.001). After adjustment, coronary malperfusion was associated with the highest odds of mortality (odds ratio [95% confidence interval]=2.28 [1.85-2.81], P<0.001) followed by mesenteric malperfusion (1.82 [1.45-2.28], P<0.001). Cerebral malperfusion was not independently associated with significantly increased odds of mortality (1.14 [0.94-1.38], P=0.18). Partial arch replacement (Zone 1 or Zone 2) compared to ascending aorta or hemiarch replacement only showed similar rate of mortality in patients with malperfusion (24.8% vs 26.9%, P=0.99) and without malperfusion (11.6% vs 13.6%, P=0.54).

Conclusions: Preoperative malperfusion in ATAAD was common and associated with significant operative mortality, which varied according to the malperfused region. Partial arch replacement, compared to ascending aorta or hemiarch replacement alone, was not associated with increased mortality.

Background: Socioeconomic disadvantage and Medicaid insurance have been linked with inferior survival following heart transplantation, yet the contributing mechanisms remain to be elucidated. We evaluated the association of Medicaid with the development of cardiac allograft vasculopathy(CAV).

Methods: We considered heart transplant recipients ≥18years within the 2004-2022 Organ Procurement and Transplantation Network. CAV was defined as any evidence of angiographic coronary disease. Institutional volume was computed, with hospitals in the highest quartile (≥19cases/year) categorized as High-Volume Centers. Patients were stratified by insurance into the Medicaid and Non-Medicaid cohorts. The study period was divided into the pre-Affordable Care Act (ACA; 2004-2013) and post-ACA eras (2014-2022).

Results: Of 37,073 heart transplant recipients, 4,875(13%) were insured by Medicaid. The overall incidence of CAV was 31%. Following risk-adjustment, Medicaid insurance was linked with significantly greater likelihood of developing CAV over 5 years (Hazard Ratio[HR] 1.08, 95%Confidence Interval[CI] 1.01-1.16). Importantly, this effect seems to have emerged in the post-ACA era (Pre-ACA HR 1.07, CI 0.84-1.36; Post-ACA HR 1.11, CI 1.02-1.21). Furthermore, among patients at High-Volume Centers, Medicaid insurance was linked with similar CAV likelihood (HR 1.04, CI 0.95-1.14). Yet, considering those treated at non-High-Volume Centers, Medicaid was associated with significantly greater CAV hazard (HR 1.14, CI 1.03-1.26). Overall, Medicaid remained associated with inferior patient (HR 1.31, CI 1.21-1.42) and allograft survival at 5-years (HR 1.29, CI 1.19-1.39).

Conclusions: Medicaid-insured recipients faced inferior survival and greater risk of CAV over 5-years. Our work encourages closer follow-up and treatment for vulnerable populations in the months and years post-transplantation.

Background: Prior investigations of the center-specific case volume on outcomes in hypoplastic left heart syndrome have conflicting results. This study utilized the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry to investigate the center volume-outcome relationship in patients following the Norwood procedure with consideration of pre-operative high-risk features.

Methods: Between 2016 and 2023, centers were categorized by Norwood procedure volume into low (≤ 5 cases/year), medium (6 to 10 cases/year), and high-volume centers (> 10 cases/year). We compared pre-operative high-risk features between the center volume categories and assessed survival outcomes, focusing on 30-day and 1-year mortality. We further compared short-term perioperative morbidity outcomes.

Results: We analyzed 3,397 patients from 69 institutions participating in NPC-QIC. Twenty-nine centers were classified as a low-, 20 as medium-, and 20 as high-volume centers. There was no difference in frequency of preoperative high-risk features among the center categories in the majority of considered variables. There was no association between the volume categories and 30-day mortality. Low-volume and medium-volume were associated with higher risk of 1-year mortality. This difference remained when adjusing for the presence of high-risk features (Low: OR (95%CI) 1.40 (1.03-1.60), P=0.020; Medium: OR (95%CI) 1.28 (1.05-1.86), P=0.025). Post-operative comorbidities were more frequent in low-, and medium-volume centers, including the need for diagnostic and interventional catheterization.

Conclusions: Patients undergoing Norwood procedure in low-, and medium-volume centers have worse 1-year mortality. The outcome characteristics are potentiated when adjusted for high-risk features with significantly higher survival and lower morbidity in patients treated in high-volume centers.