Annals of Thoracic Surgery最新文献

Background: Tunnel-type left ventricular outflow tract obstruction (LVOTO) in children requires extensive resection of long-segment fibromuscular narrowing and is traditionally treated with Konno or modified Konno procedures, which involve right ventriculotomy and may risk right ventricular dysfunction and conduction injury.

Methods: Between 2012 and 2023, 26 children (mean age 5.4 ± 1.3 years; 34.6% with prior septal myectomy) underwent repair of tunnel-type LVOTO using a combined transaortic and right atrial approach at three tertiary centers. The operation consisted of transaortic exposure, controlled creation of an iatrogenic membranous ventricular septal defect to access deep obstructive tissue, bidirectional resection via the aortic root and right atrium, and patch closure of the septal defect from the right atrium.

Results: There was no early or late mortality. The mean left ventricular-aortic gradient decreased from 67.6 ± 11.9 mm Hg preoperatively to 15.8 ± 5.0 mm Hg at last follow-up (p < 0.0001). Freedom from reoperation at 5 years was 96.2%, with one patient (3.8%) reoperated for aortic insufficiency. Right bundle branch block occurred in 23.1% of patients, but no complete heart block was observed. Right ventricular systolic function showed only modest reductions from baseline. CONCLUSİONS: A transaortic and right atrial, right ventricle-sparing approach can achieve durable relief of tunnel-type LVOTO in children while preserving right ventricular function and avoiding right ventriculotomy, and may represent a useful alternative to modified Konno repair.

Background: A recent consensus statement recommends that atypical cells are considered non-diagnostic specimens in the calculation of diagnostic yield. We investigated the natural history and malignancy rate of atypical cells and practice patterns of clinicians encountering these biopsy results.

Methods: This is a subset analysis of a prospective, multicenter study evaluating the safety and diagnostic outcomes of robotic-assisted bronchoscopy for pulmonary nodules. Non-diagnostic samples including those with and without atypical cells were included for this analysis, with an ultimate diagnosis of benign if lesion size remained stable or decreased through 12 months, or malignant if enlarging on CT or based on repeat biopsy. Lesion characteristics and clinical outcomes were compared with Fisher's exact test.

Results: Of 679 patients in the study, 196 had non-diagnostic biopsy without atypical cells (NDwo) and 47 non-diagnostic biopsies had evidence of atypical cells (NDwA). Pre-test probability for malignancy was similar (79% NDwo and 83% NDwA medium risk with Brock University prediction, p=0.870). Malignancy was the final diagnosis in 33% of NDwo and 68% of NDwA (p<0.001). 48% of NDwo and 26% of NDwA were diagnosed as benign, and 19% and 6% of NDwo and NDwA, respectively, were inconclusive. 21% of NDwA, compared with 4.6% NDwo, were referred directly to cancer therapy without repeat imaging or biopsy (p<0.001).

Conclusions: Over two-thirds of biopsies resulting as NDwA manifest in malignancy on follow up. One in 5 patients with these results are referred to treatment without further interventions.

Background: National data on the durability of surgical mitral repair and outcomes of reintervention are lacking. We aimed to quantify the national incidence and outcomes of mitral reintervention after surgical repair.

Methods: United States Centers for Medicare Services claims identified patients ≥65 years undergoing surgical mitral repair followed by reintervention (replacement, re-repair, or transcatheter edge-to-edge repair (TEER)) between 2012-2023. Thirty-day and three-year mortality, stroke, and heart failure readmission following reintervention were assessed using logistic regression and adjusted Cox-proportional hazard modeling. Competing risks were used to estimate the probability of reintervention, heart failure and stroke.

Results: Of 45,482 patients undergoing surgical mitral repair, 1,560 required reintervention. Of these, 1,223 (78.4%) had surgical replacement, 164 (10.5%) surgical repair, and 173 (11.1%) TEER. Median time to reintervention was 1.9 years (IQR: 0.64-4.1 years).). The cumulative incidence of reintervention at nine years was 5%. Adjusted thirty-day rate of heart failure readmission was lowest among patients undergoing TEER (4.8% versus 15.9% replacement, 14.6% re-repair, p<0.01), while thirty-day mortality and stroke readmission rates did not differ between reintervention approaches. At three years, there was no significant difference in survival, heart failure readmissions, or stroke readmissions by reintervention approach.

Conclusions: Surgical mitral repair is durable with a low nine-year risk of reintervention. Reintervention approach does not impact mortality, heart failure, and stroke readmissions at three years, suggesting that either approach is appropriate for reintervention.

Background: Despite increasing radial artery use in multivessel coronary artery bypass grafting (CABG), the optimal harvesting technique remains uncertain. We compared short- and long-term outcomes after multivessel CABG using endoscopic versus open radial artery harvesting at the population level.

Methods: In the Centers for Medicare and Medicaid Services database, 6,840 adults underwent isolated, first-time, multivessel, non-emergent CABG with radial artery use between 2015 to 2022: 3,938 (57.6%) underwent endoscopic and 2,902 (42.4%) underwent open radial harvest. The primary outcome was a composite of major adverse cardiac events (MACE) defined as death, myocardial infarction, or repeat revascularization at 5-years, compared after propensity matching on 26 variables in a Cox proportional hazards model. Secondary outcomes included length of stay, 30-day mortality, 1-year wound and vascular complications.

Results: Endoscopic patients were younger (median 69 years [IQR: 66-73] vs 70 years [66-74], p=0.002), less likely female (16.8% vs 19.3%, p=0.008), and had lower prevalence of heart failure (27% vs 30.6%, p=0.001). Propensity matching yielded 2,776 well balanced pairs. Endoscopic patients had shorter hospital stays (6 days [5-9] vs 7 days [5-9], p=0.02), similar 30-day mortality (1.4% vs 1.2%, p=0.35), and similar 1-year wound (4.0% vs 4.8%, p=0.12) and vascular complications (0.3% vs 0.4%, p=0.65) compared to open harvest. Five-year freedom from MACE was equal between groups (81.1% vs 80.8%, HR: 1.02, 95%CI: 0.88-1.18, p=0.83).

Conclusions: There were no differences in late major adverse cardiac events with endoscopic compared to open radial artery harvesting in patients undergoing multivessel CABG.

Background: Comparative durability of subsequent procedures after transcatheter aortic valve replacement (TAVR) remains unclear. This study aims to assess long-term outcomes of Repeat TAVR versus TAVR Explant for bioprosthetic valve dysfunction post-TAVR.

Methods: Medicare beneficiaries undergoing aortic valve reintervention after index TAVR (January 2012 - December 2020) were categorized as Repeat TAVR or TAVR Explant. Exclusion criteria included endocarditis or reintervention during the same admission. Primary outcome was 5-year mortality; secondary outcomes included major adverse cardiovascular events (death, pacemaker placement, major bleeding, stroke, AKI, cardiac arrest). Time-to-event analyses utilized Kaplan-Meier. Adjusted outcomes were assessed via 1:1 propensity matching.

Results: Among 1,172 patients undergoing reintervention after TAVR, 70.6% had Repeat TAVR and 29.4% had TAVR Explant. Repeat TAVR patients were older, more often female, with higher Charlson Comorbidity score (all p<0.05). Median follow-up was 29.2 months (27.7 months Repeat TAVR, 32.3 months TAVR Explant). In the propensity-matched cohorts, 30- and 90-day mortality was higher after TAVR Explant, but Kaplan-Meier estimated cumulative mortality was lower in TAVR Explant at 3 and 5 years (all p<0.001). Survival curves crossed at ∼9months, after which TAVR Explant maintained a persistent advantage. The hazard ratio over the entire follow-up was 0.61 (95% CI 0.49-0.75, p<0.001). Similar survival patterns were observed across Charlson comorbidity stratification and after excluding concomitant procedures.

Conclusions: Although Repeat TAVR showed lower short-term mortality, long-term outcomes favored TAVR Explant. These findings suggest that among Medicare beneficiaries experiencing TAVR failure, there is a subset of patients who could benefit from TAVR Explant over Repeat TAVR.