Annals of Thoracic Surgery最新文献

Background: Trials comparing transcatheter (TAVR) and surgical aortic valve replacements (SAVR) have shown that in patients with annuli <26 mm, SAVR had negative hemodynamic and clinical outcomes. Recently, studies revealed that the effective orifice diameter of surgical prosthetic valves is 5-7 mm smaller than the labeled valve size. To improve outcomes of SAVR, the Y-incision aortic annular enlargement (AAE) enlarges the surgical aortic annulus to accommodate a prosthetic valve 3-4 sizes larger with an effective orifice area that matches the patient's native annulus. This review discussed when and how the Y-incision AAE should be performed.

Methods: OVID MEDLINE, OVID Embase, and Cochrane Library were searched with terms that included "Y-incision aortic annular enlargement," "valve sizes," and "long-term survival." The search included publications after 2020. The reference lists of included studies were reviewed to retrieve additional studies.

Results: In patients with matched native annular sizes, AAE significantly improved midterm survival without increasing perioperative complications. Patients treated with a larger valve had significantly better long-term survival and small valve sizes were significant risk factors for operative and long-term mortality. Compared with patients treated with a Nicks or Manougian procedure, the hemodynamics in patients treated with Y-incision AAE were significantly better.

Conclusions: Y-incision AAE could be routinely considered for patients with a normal annulus (17-25 mm) undergoing SAVR.

Background: Early tracheostomy improves outcomes in the adult population, but there is little evidence of benefit in the pediatric population. We investigated hospital and late survival of tracheostomy placement in patients who also underwent congenital cardiac surgery.

Methods: A single-center review of 65 consecutive patients who underwent tracheostomy placement and cardiac surgery in a pediatric hospital between 2011 and 2022 was performed. Multivariable logistic regression analysis was performed to assess predictors of mortality, and a Kaplan-Meier estimate was performed to evaluate mortality.

Results: Final analysis included 62 patients. Median birth weight and age at tracheostomy admission was 2.7 kilograms (IQR 2,3) and 175 days (IQR 107,266), respectively. Patients failed extubation a median of 3 times (IQR 1,4). Duration of ventilation before tracheostomy was 85 days (IQR 49,106). Thirty-nine patients (63%) were discharged from the hospital. Thirty-eight patients (61%) died overall, of which 21(55%) died in-hospital. Median survival was 328 days (IQR 94,1711). Independent predictors of mortality were longer LOS (OR 4.66 [1.6,13.8], P<0.01), tracheomalacia (OR 0.31 [0.1,0.93], P=0.04), sepsis (OR 3.4 [1.18,10], P=0.02), pneumonia before or after tracheostomy (OR 3.3 [1.1,10.2], P=0.04), and acute kidney injury requiring dialysis (OR 8 [1.96,54.5], P=0.01).

Conclusions: With 61% mortality after tracheostomy in patients undergoing cardiac surgery in a pediatric hospital, one can wonder whether this practice improves survival in these patients. Families should be warned that, in the sickest patients, tracheostomy may only offer increased survival for a limited time.

This article provides a comprehensive exploration of how artificial intelligence (AI) is reshaping medical education and the role of traditional textbooks. The historical context underscores the evolution of medical knowledge bridging past advances with current AI-driven innovations, highlighting the indispensable role of both printed and electronic medical textbooks. The strengths and limitations of traditional and digital textbooks are considered. The potential for AI to enhance medical education through real-time updates, personalized learning, and advanced visual aids is particularly compelling. This perspective is critical for practitioners and educators who are navigating the integration of AI in their fields.

Background: The significance of evaluating myocardial viability in making decisions regarding coronary artery bypass graft surgery (CABG) for ischemic left ventricular dysfunction (ILVD) patients remains controversial. The study aimed to examine the impact of integrated assessment of hibernating myocardium and scars on the survival benefit associated with CABG in patients with ILVD.

Methods: Consecutive patients with ILVD who underwent ¹⁸F-fluorodeoxyglucose positron emission tomography and cardiac magnetic resonance imaging with late gadolinium enhancement viability testing from January 2015 and April 2018 were retrospectively enrolled. The primary endpoint was all-cause death. The secondary endpoint was a composite of cardiovascular death, cardiovascular hospitalization, heart transplantation, revascularization, implantation of an implantable cardioverter defibrillator, or non-fatal stroke. Cox models calculated hazard ratios (HRs) and confidence intervals (CIs) for CABG versus medical therapy alone for subgroups with different levels of hibernation and scars.

Results: During a median follow-up of 71.5 months of 507 patients, 98 patients reached the primary endpoint and 194 reached the secondary endpoint. After adjustment, CABG was associated with lower risks of all-cause mortality (HR 0.249, 95%CI 0.154-0.428, P<0.001) and lower incidences of secondary outcomes (HR 0.457, 95%CI 0.318-0.658, P<0.001) compared to medical treatment alone in overall population. Across all four subgroups classified by the optimal cut-off value (10% hibernation and 26% scar), CABG was associated with favorable outcomes regardless of the hibernation and scar level.

Conclusions: The extent and severity of hibernating myocardium and scars appears not to impact the effects of CABG in patients with ILVD.

Background: Coronary artery bypass grafting (CABG) remains a cornerstone in the management of coronary artery disease (CAD). In non-urgent surgical revascularization cases, preoperative optimization of modifiable risk factors can improve outcomes. There is increasing interest in the relationship between lipoprotein(a) levels and the risk for ischemic cardiovascular disease, particularly how CABG outcomes are in turn affected. This review highlights the role of Lp(a) in the pathogenesis of CAD and CABG outcomes and discusses future directions for its optimal management in the perioperative period.

Methods: A review of the PubMed/MEDLINE database until March 2024 was performed to capture publications that evaluated and/or described the relationship between lipoprotein(a) and CABG surgery or CAD outcomes.

Results: The available literature supports lipoprotein(a) as a causal and independent risk factor for the pathogenesis of CAD. Elevated lipoprotein(a) levels are associated with an increased risk of adverse post-CABG outcomes, including graft occlusion incidence and major adverse cardiovascular events. Genetic variations influencing lipoprotein(a) levels play a role in disease progression and surgical outcomes. Several therapies aimed at reducing lipoprotein(a) levels, currently in phase III clinical trials, show promise for improving post-CABG prognosis.

Conclusions: Among individuals undergoing surgical revascularization for CAD, lipoprotein(a) levels may help define risk and inform best practices for perioperative management. We advocate for the routine measurement of lipoprotein(a) in all patients undergoing CABG. Emerging lipoprotein(a)-lowering agents show promise for secondary prevention of cardiac events, though dedicated analyses in cardiac surgical sub-cohorts will be important to evaluate their role in improving CABG outcomes.

Background: Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is associated with poor outcomes. Mild PVL remains prevalent post-TAVI and its impact on long-term survival is unclear. This study aims to examine the incidence, impact on survival, and progression of PVL.

Methods: This was a retrospective, single-institution cohort study of TAVIs between 11/2012-1/2023. Patients were stratified by 30-day PVL severity: none/trace, mild, and ≥ moderate. Multivariable logistic regression was performed to identify risk factors associated with increasing PVL severity. Kaplan-Meier survival estimation and Cox proportional hazards regression were performed.

Results: 3600 patients underwent TAVI. Of these, 2719 (75.5%) had none/trace PVL, 808 (22.5%) had mild PVL, and 73 (2.0%) had ≥ moderate PVL at 30-days. On multivariable logistic regression, later years of valve implantation (2017-2023) were protective against PVL progression. Kaplan-Meier estimates of the three groups were significantly different (p<0.001) with the ≥ moderate group having reduced survival. On Cox regression, ≥ moderate PVL was associated with increased mortality (HR = 1.80, 95% Cl, 1.31-2.46, p<0.001) while mild PVL was not (HR = 1.01; 95% CI, 0.89-1.15; p=0.88) compared to none/trace PVL. For Kaplan-Meier estimates comparing the none/trace and mild PVL groups alone, landmark analysis showed reduced survival in the mild PVL group after 2-years (p=0.03); however, this late reduction in survival in the mild PVL group did not persist on multivariable analysis (p=0.14).

Conclusions: After TAVI, ≥ moderate PVL is associated with reduced survival compared to none/trace PVL. Mild PVL may result in a delayed survival reduction.

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) remains the largest and most comprehensive audited thoracic surgical database in the world. As the STS GTSD grows to nearly 1 million cases, the pulmonary resection for cancer and esophagectomy short-term risk models have been refined to provide participants with benchmarked performance reports to facilitate quality improvement efforts. New for 2025 will be the development of long-term risk models and the online release of both short- and long-term risk calculators. A voluntary module to collect neoadjuvant targeted and immunotherapy data has been created has been accepted by participants and is rapidly accruing data. STS GTSD participant public reporting has increased 50% over the last 2 years following the application of the US News and World Report 3% transparency credit. All GTSD data analyses are now performed internally by the STS Research and Analytic Center, resulting in multiple publications through the Access & Publication, Task Force on Funded Research, and Participant User File mechanisms. Future initiatives include the incorporation of patient-reported outcomes into the STS GTSD, revision of the data collection form to incorporate variables associated with long-term outcomes, and focused efforts to increase the value of STS GTSD participation. This report delineates volume trends, recent initiatives, and the prolific research output emanating from the STS GTSD, reflecting a year of substantial progress and academic productivity.

Transcatheter aortic valve-in-valve replacement presents a viable, minimally invasive approach to replacing degraded bioprosthetic surgical valves. The major drawback of this technique is poor hemodynamics in the form of patient-prosthesis mismatch and high transvalvular gradients. This is commonly attributable to the reduced valvular diameter from the transcatheter heart valve fixed inside the degraded bioprosthesis. Maximizing this diameter via bioprosthetic valve fracture occurs through a noncompliant, high-pressure balloon to splay the degraded valve outward. Despite its novelty, this has demonstrated improved hemodynamic outcomes and optimal valvular expansion with slightly increased operative risk. In this review, we highlight the technique of bioprosthetic valve fracture, types of suitable balloons and valves, timing in relation to valve-in-valve implantation, safety and efficacy, implications, and future directions.

Background: Statistical risk models for durable left ventricular assist device (LVAD) implantation inform candidate selection, quality improvement, and evaluation of provider performance. This study developed a 90-day mortality risk model using The Society of Thoracic Surgeons National Intermacs Database (STS Intermacs).

Methods: STS Intermacs was queried for primary durable LVAD implants from January 2019 to September 2023. Multivariable logistic regression was used to derive a model based on preimplant risk factors by using derivation (2019-2021 implants) and validation (2022-2023 implants) cohorts. Model performance (derivation and validation cohorts) was assessed using C-statistics, Brier scores, and calibration plots. A refined model (all patients) was generated to calculate observed-to-expected (O/E; 95% CI) ratios for each center.

Results: The study population consisted of 11,342 patients from 2019 to 2023 who were sequentially divided in time into derivation (n = 6775) and validation (n = 4567) cohorts. Ninety-day mortality was 8.0% (9.2% in the derivation cohort vs 7.4% in the validation cohort; P = .001). Logistic regression applied to derivation and validation cohorts produced similar discrimination (area under the curve [AUC], 0.714 [95% CI, 0.69-0.74]; and AUC, 0.707; [95% CI, 0.67-0.72], respectively) and calibration (Brier score, .08 vs .07), with overestimation of risk among patients with a predicted risk >0.4. The O/E analysis identified 22 (12.5%) centers with worse than expected mortality with a 95% CI >1.0 and 14 centers (8.0%) with better than expected mortality with a 95% CI <1.0 (all P < .05).

Conclusions: The STS Intermacs risk model demonstrated satisfactory discrimination and calibration. This tool may be used to inform candidate selection, facilitate quality improvement, and assess provider performance.

Background: As percutaneous therapeutic options expand, the optimal management of severe aortic stenosis (AS) and concomitant coronary artery disease (CAD) is being questioned between coronary artery bypass grafting with surgical aortic valve replacement (CABG+SAVR) and percutaneous coronary intervention with transcatheter aortic valve replacement (PCI+TAVR). This study sought to compare perioperative and longitudinal risk-adjusted outcomes between patients undergoing CABG+SAVR and patients undergoing PCI+TAVR.

Methods: Using the Centers for Medicare & Medicaid Services inpatient claims database, the study evaluated all patient aged 65 years and older with AS and CAD who were undergoing CABG+SAVR or PCI+TAVR (from 2018 to 2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk adjustment using inverse probability weighting, multilevel regression, and competing-risk time to event analyses. The primary end point was a 5-year composite of stroke, myocardial infarction (MI), valve reintervention, or death.

Results: A total of 37,822 patients formed the study cohort (PCI+TAVR, n = 17,413; CABG+SAVR, n = 20,409). Accounting for age, comorbidities, frailty, and number of vessels revascularized, PCI+TAVR was associated with lower procedural mortality (1.1% vs 3.6%; odds ratio [OR], 0.29; P <.001) but higher vascular complications (OR, 6.02; P <.001) and new permanent pacemaker (OR, 1.92; P <.001). However, the longitudinal 5-year primary end point favored CABG+SAVR (20.4% vs 14.2%; OR, 1.44, P <.001). Subgroup analyses demonstrated a benefit in the use of arterial conduit in CABG+;AVR in patients with single-vessel CAD.

Conclusions: Among Medicare beneficiaries with severe AS and CAD, CABG+SAVR was associated with higher procedural mortality than PCI+TAVR but lower 5-year risk-adjusted stroke, MI, valve reintervention, and death.