Annals of Thoracic Surgery最新文献

Background: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is associated with improved perioperative safety compared to redo surgical aortic valve replacement (redo-SAVR), but long-term outcomes remain uncertain. We therefore compare long-term outcomes of ViV-TAVR and redo-SAVR.

Methods: The study included 1:1 propensity-matched Medicare beneficiaries with degenerated bioprosthetic valves admitted between 09/29/2011 and 12/30/2020 undergoing either redo-SAVR or ViV-TAVR. Exclusion criteria included endocarditis, other concomitant cardiac surgery, or aortic valve re-intervention during the same admission. The primary outcome was 5-year survival. Composite secondary outcomes included major adverse cardiovascular events (MACE; 30-day operative mortality, stroke, or acute myocardial infarction) and major valve event-free survival (congestive heart failure readmission, endocarditis, or aortic valve reintervention). Time-to-event analyses utilized Kaplan-Meier analysis and multivariable Cox proportional hazard modeling.

Results: Overall, 4,699 patients were identified including 1,775 redo-SAVR and 2,924 ViV-TAVR patients. Redo-SAVR patients were younger (median[IQR] 72[68,77] vs 79[73,84]) with less CHF(39.6% vs. 68.8%) and prior CABG (17.9% vs. 32.0%) (all p<0.05). In the propensity-matched cohorts of 1,256 patients each, redo-SAVR had higher MACE (17.4% vs 13.2%, p=0.003), but better major valve event-free (71[62,79] vs 43[38,47] months, p<0.001) and 5-year (62.3% vs 46.7%, p<0.001) survival. After stratification by Charlson Comorbidity Index, the long-term survival benefit persisted in patients of lower (67.6% vs 54.9%, p=0.001) and medium or higher-risk (55.1% vs 36.7%, p<0.001).

Conclusions: Redo-SAVR may have better long-term survival than ViV-TAVR despite greater perioperative morbidity. Clinical trial data is needed to fully inform clinical decision-making regarding degenerated bioprosthetic valve reintervention, particularly for patients with reasonable life expectancy.

Background: The etiology of increased risk for reoperation after transcatheter aortic valve replacement (TAVR) versus prior surgical aortic valve replacement (SAVR) is poorly understood. This study evaluated the impact of concomitant mitral and tricuspid valve disease on associated risk of TAVR explant.

Methods: Patients undergoing aortic valve replacement after prior SAVR or TAVR were extracted from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2021). Patients were stratified by TAVR explant status and presence of severe concomitant valve disease for analyses. Risk adjustment was performed using multivariable logistic regression. Interaction terms were utilized to evaluate differential risk of concomitant valve disease for TAVR explant versus redo-SAVR.

Results: Of 24,097 redo aortic valve replacement patients, 877 (3.6%) underwent TAVR explant. TAVR explant patients had higher rates of concomitant severe valve disease (17% vs 14%, p<0.001). Patients with severe concomitant valve disease had worse operative mortality after TAVR explant (26.2% vs 14.6%, p<0.001) and redo-SAVR (12.3% vs 6.9%, p<0.001). TAVR explant was independently associated with higher mortality (OR_adj 1.3 [1.0-1.6], p=0.030). Severe mitral regurgitation (OR_adj 1.2 [1.0-1.6], p=0.017), mitral stenosis (OR_adj 2.0 [1.5-2.7, p<0.001), and tricuspid regurgitation (OR_adj 1.6 [1.3-1.9], p<0.001) were all associated with mortality, although these factors were not associated with disproportionately higher risk during TAVR explant (p>0.05).

Conclusions: TAVR explant cases have a higher burden of severe concomitant valve disease than redo-SAVR cases. Heart teams should consider these findings when discussing initial procedure choices for patients with multi-valve disease given their extreme risk at time of TAVR explant.

Background: To evaluate the proportion of lung cancer patients who would have qualified for lung cancer screening under different eligibility criteria in the Boston Lung Cancer Study (BLCS).

Methods: BLCS participants diagnosed with lung cancer from 1992-2024 were identified for analysis. The proportion of patients who would have qualified for screening under the 2021 U.S. Preventive Services Task Force (USPSTF) (age 50-80, >20-pack-years, <15 quit-years), 20-year duration (age 50-80, 20-year smoking duration, <15 quit-years), American Cancer Society (age 50-80, >20-pack-years), NCCN-category-A (age >50, >20-pack-years), and NCCN-category-AB (aged >50, >20 pack-years OR >20-year smoking duration) guidelines were evaluated. We also evaluated the proportion of patients with a smoking history ineligible for screening under the aforementioned guidelines who had a PLCOm2012 risk score > 1.0%.

Results: Of 7,186 patients meeting inclusion criteria, 33.4% currently smoked, 52.1% formerly smoked, and 14.5% had never smoked. Among these patients, 46.1% met the USPSTF guideline, 48.9% met the 20-year duration guideline, 61.0% met the American Cancer Society guideline, 66.1% met the NCCN-category-A guideline, and 71.7% met the NCCN-category-AB guideline. While the PLCOm2012 1.0% risk threshold identified 52.2% of patients with a smoking history who were ineligible for screening under the USPSTF criteria, the PLCOm2012 1.0% risk threshold excluded the majority of patients with <20 pack-years.

Conclusions: In this analysis of 7,186 lung cancer patients, only 46.1% would have met the USPSTF criteria. Including a smoking duration criterion and removing the 15-years-since-quitting criterion from the USPSTF guideline would increase the proportion of patients eligible for screening.

Background: Prospective randomized trials have demonstrated noninferior survival between sublobar resection and lobectomy in healthy non-small cell lung cancer (NSCLC) patients with tumors ≤2cm. However, some patient attributes are not well represented in randomized trials and uncertainty remains in the widespread applicability of randomized trial nodal dissection protocols.

Methods: Patients with ≤2cm, node-negative NSCLC (cT1N0) in the Society of Thoracic Surgeons prospective database were linked to Medicare survival data using a probabilistic matching algorithm. Survival was assessed by propensity score weighted Kaplan Meier analysis.

Results: Overall, 20,031 patients were identified including 11,976 lobectomy, 2,586 segmentectomy, and 5,469 wedge resection patients. Fewer lymph nodes were sampled in sublobar patients (mean 5.5 vs 12.8) and pathologic upstaging was less common (7.1% vs 14.2%). Overall survival following sublobar and lobar resection was similar within groups under-studied in recent trials including age ≥75 years (p=0.07), FEV1=10-59% (p=0.14), and Zubrod performance status 2-3 (p=0.23). When sublobar resection was performed with inadequate nodal evaluation (<2 nodes removed), the survival was inferior to lobectomy (p<0.001). Among patients with nodal upstaging, lobectomy was not associated with improved survival over sublobar resection (p=0.42).

Conclusions: The clinical trial finding that sublobar resections achieve similar survival to lobectomy in early-stage lung cancer appears to apply to older, less healthy patients in a real-world setting, provided adequate lymph node resection is performed. Performing a lobectomy in the setting of nodal upstaging, does not obviously improve survival. Further study is warranted to clarify the role of sublobar resection in the general population.

Background: The effect of anticoagulation on early postoperative outcomes following pulmonary valve replacement (PVR) with bioprosthetic valves and homografts is not yet defined. We hypothesized that short-term anticoagulation would be associated with improved valve durability.

Methods: Patients undergoing PVR or right ventricle-pulmonary artery conduits with a bioprosthetic or homograft valve >15 mm in diameter between 1/2015 and 4/2021 at Boston Children's Hospital were retrospectively compared by anticoagulation status. Survival, postoperative echocardiographic data, and the incidence of pulmonary valve reintervention and prosthetic valve dysfunction were compared using multivariable Cox and logistic regression analyses adjusted for a propensity score based on anticoagulation therapy.

Results: Among a total of 531 patients with a median follow-up of 1.16 years, 130 received anticoagulation therapy. Freedom from reintervention was 99%, 92%, and 86% at 1, 3, and 5 years, respectively. Adjusted for propensity score, there was no association between reintervention and anticoagulation (hazard ratio 0.78 [95% CI: 0.18-3.47], p=0.75). The propensity-score-adjusted rates of valve dysfunction were 9% in anticoagulated patients and 15% in nonanticoagulated patients (odds ratio 0.54 [95% CI 0.18-1.56], p=0.25). There was no difference in early major bleeding rates between groups (3.4% vs. 2.4%, p=0.59) nor other postoperative outcomes. Only 1/18 (6%) of all bleeding events in the anticoagulated group occurred after starting anticoagulation.

Conclusions: Anticoagulation therapy appeared safe with no association with major postoperative bleeding. However, additional follow-up is necessary to assess its impact on mid- to long-term valve durability following PVR.

Background: Management guidelines for stable three-vessel coronary artery disease have become a subject of debate. We aim to provide a benchmark for the survival of patients with normal ejection fraction, stable three-vessel disease, and elective coronary artery bypass graft (CABG) surgery.

Methods: Data from consecutive patients with normal ejection fraction undergoing elective primary isolated CABG for triple-vessel disease in a diverse 11-center surgical network between 2008 and 2020 were analyzed. Survival data were obtained from the Centers for Disease Control and Prevention National Death Index and compared with an age- and sex-matched U.S.

Population: Mixed effects modeling with 'hospital' as a random effect was used to evaluate factors associated with all-cause mortality.

Results: Of 4,061 patients included in this analysis, 22% (893/4,061) were female and median age was 68 (IQR 61,74). Patients with elective CABG surgery for three-vessel disease and normal ejection fraction demonstrated improved survival compared to an age and sex-matched U.S. population, with significantly increasing relative survival over time. Factors associated with mortality included age ≥ 65 years (Hazard Ratio (HR) 1.71, p<0.001), male gender (HR 1.32, p=0.028), diabetes (HR 1.4, p=0.002), dialysis (HR 2.41, p=0.03), moderate or severe chronic lung disease (HR 1.68, p<0.001), and peripheral arterial disease (HR 2.05, p<0.001).

Conclusions: Patients with stable three vessel disease and normal ejection fraction who underwent elective CABG demonstrated improved survival compared to an age and sex-matched U.S.

Population: With this benchmark, further research can better elucidate the relative role of surgery and medical therapy in this patient population.

Background: Valve-sparing root replacement(VSRR) with the David technique is an established therapy for aortic root pathology in young patients. The aim of this study was to evaluate short and long-term outcomes between VSRR and aortic root replacement(ARR) with a biological-valved conduit in sexagenarians.

Methods: A multicenter retrospective review from 2002-2022 identified 299-sexagenarians undergoing aortic root surgery, among whom 82(27.4%) underwent VSRR and 217(72.6%) bio-Bentall. Inverse probability of treatment weighting(IPTW) was applied to balance clinical variables. Median follow-up was 15-years[12-18 years]. Endpoints of the study were in-hospital mortality, long-term survival, freedom from reintervention and recurrence of at-least-moderate AR.

Results: There were no major differences in baseline characteristics. The incidence of bicuspid valves(VSRR 4.9% vs ARR 19%), severe AR(42% vs 51%), type-A aortic dissection(1.2% vs 6.9%), and reoperation(4% vs 23%) were higher in ARR. Following IPTW, there was no difference in in-hospital mortality(VSRR 1.2% vs ARR 4.6%,p=0.3). The incidence of neurologic complications(p=0.003), and permanent pacemaker(PPM) implantation(p=0.022) were significantly higher in the bio-Bentall group. After IPTW, 10-year survival did not differ between VSRR(87%) and ARR(80%)(p=0.176). However, cardiac-survival was significantly higher in VSRR patients(98% vs 92%,p=0.018), with deaths mainly due to infective endocarditis and end-stage heart failure(HF). Regarding reoperation/recurrence of at-least-moderate AR, no difference was reported among groups at 10-years, with only 1-patient undergoing reintervention following bio-Bentall(p=0.117).

Conclusions: David and bio-Bentall procedures have low in-hospital mortality and good long-term survival in sexagenarians. VSRR is associated with improved long-term cardiac-survival, lower rates of infective endocarditis, PPM-implantation and HF-episodes, with similar rates of reintervention/recurrence of moderate AR.

Background: Anastomotic leak after esophagectomy is a major cause of morbidity and mortality. We sought to identify the prevalence of anastomotic leak, stratified by operative approach and disease etiology, as well as risk factors for leak.

Methods: A retrospective cohort analysis using the STS General Thoracic Surgery Database was conducted on patients who underwent esophagectomy with gastric reconstruction between 2009-2021. Baseline characteristics and postoperative outcomes were compared between patients who did and did not develop an anastomotic leak. Multivariable mixed effects logistic regression models identified risk factors for leak.

Results: Of 18,419 patients, 3,416 (19%) developed an anastomotic leak. Patients who leaked had more comorbidities including obesity and diabetes. There was no difference in leak based on disease etiology (p=0.435.) Patients with anastomotic leak had increased 30-day mortality (7% vs 4%, p<0.001), reoperation (58% vs 10%, p<0.001), and longer lengths of stay (18 vs 10 days, p<0.001). On multivariable analysis, obesity (OR 1.27[1.16-1.38], p<0.001), diabetes (OR 1.14[1.04-1.25], p=0.006), and smoking (OR 1.26[1.15-1.37], p<0.001) were independently predictive of anastomotic leak. Compared to an open 2-field, a transhiatal (OR 1.35[1.17-1.55], p<0.001) or 3-field esophagectomy (OR 1.46[1.25-1.70], p<0.001) was more likely to leak. A robotic approach was associated with an increased risk of leak (OR 1.28[1.03-1.08], p<0.001), however lost significance in a modern subgroup from 2018-2021.

Conclusions: Obesity, diabetes, smoking, pulmonary hypertension, and a cervical anastomosis are risk factors for anastomotic leak regardless of disease etiology. These important clinical risk factors identify an opportunity for modifiable risk reduction with aggressive medical optimization perioperatively.

Background: The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs), supported by The Society of Thoracic Surgeons, provides detailed information on pediatric patients supported with ventricular assist devices (VADs).

Methods: From September 19, 2012, to December 31, 2023, there were 1648 devices in 1349 patients (<19 years) from 39 North American Hospitals with 100 patients enrolled in 2023.

Results: Cardiomyopathy was the most common underlying etiology (59%), followed by congenital heart disease (26%) and myocarditis (8%). Regarding device type, implantable continuous VADs were most common at 37%, followed by paracorporeal continuous (28%) and paracorporeal pulsatile (28%) and percutaneous (7%). Baseline demographics differed, with the paracorporeal continuous cohort being younger, smaller, more complex (ie, congenital heart disease), and sicker at implantation (p< .0001). At 6 months after VAD implantation, a favorable outcome (transplantation, recovery, or alive on device) was achieved in 84% of patients, which was greatest among those on intracorporeal VADs (92%) and least for paracorporeal continuous VADs (71%). Survival for single ventricle patients is similar to other congenital heart disease patients but inferior to those with cardiomyopathy. Survival for single ventricles varies by stage of palliation.

Conclusions: This Eighth Pedimacs Report demonstrates the important role in VAD support in the care of children with end stage heart disease. The complexity of cardiac physiologies and anatomic constraint mandates the need for multiple types of devices used. The pre-implantation characteristics and different patient populations likely account for some of the differences in outcomes amongst the different device types.