Annals of Thoracic Surgery最新文献

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 and surgical aortic valve replacement (CABG+SAVR) versus percutaneous coronary intervention and transcatheter aortic valve replacement (PCI+TAVR). We sought to compare perioperative and longitudinal risk-adjusted outcomes between patients undergoing CABG+SAVR versus PCI+TAVR.

Methods: Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patient age 65 and older with AS and CAD undergoing CABG+SAVR or PCI+TAVR (2018-2022). 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 endpoint was 5-year composite of stroke, myocardial infarction (MI), valve reintervention and/or death.

Results: A total of 37,822 patients formed the study cohort (PCI+TAVR, n=17,413; CABG+AVR, 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%, OR 0.29, p < 0.001), but higher vascular complications (OR 6.02, p < 0.001) and new permanent pacemaker (OR 1.92, p < 0.001). However, the longitudinal 5-year primary endpoint favored CABG+SAVR (20.4% vs 14.2%, OR 1.44, p < 0.001). Subgroup analyses demonstrated a benefit in the use of arterial conduit in CABG+SAVR 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.

Background: Before lung cancer resection, patients inquire about dyspnea and the potential need for supplemental oxygen. The objective of this study was to identify predictors of discharge with supplemental oxygen for patients undergoing lobectomy for lung cancer.

Methods: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, study investigators conducted a retrospective cohort study of patients who underwent lobectomy for lung cancer from July 2018 to December 2021. Multivariable logistic regression was used to determine the adjusted association of pulmonary function with discharge on supplemental oxygen and identify independent predictors of discharge with supplemental oxygen. Pulmonary function was modeled as the minimum of either predicted postoperative forced expiratory volume in 1 second or predicted postoperative diffusing capacity of lung for carbon monoxide.

Results: Overall, 2100 (8.4%) patients who underwent lobectomy were discharged with supplemental oxygen. Those patients with a minimum of either predicted postoperative forced expiratory volume in 1 second or predicted postoperative diffusing capacity of lung for carbon monoxide ≤60% had a progressively increased risk of discharge with supplemental oxygen than patients with minimum function >60%. The 2 strongest predictors of discharge with supplemental oxygen were increasing body mass index (25-29 kg/m²: adjusted odds ratio [aOR], 1.38; 95% CI, 1.21-1.57; 30-39 kg/m²: aOR, 2.14; 95% CI, 1.88-2.45; ≥40 kg/m²: aOR, 3.51; 95% CI, 2.79-4.39; reference, 18.5-24 kg/m²) and former (aOR, 2.04; 95% CI, 1.67-2.52) or current (aOR, 2.61; 95% CI, 2.10-3.26) smoking status (reference, never smoker).

Conclusions: Of those patients who underwent lobectomy for lung cancer, 8.4% were discharged with supplemental oxygen. The study identified preoperative independent predictors of discharge with supplemental oxygen that may be useful during shared decision-making discussions of treatment options for lung cancer and setting expectations with patients.

Background: The contemporary management and resectability of locally advanced lung cancer are undergoing significant changes as new data emerge regarding immunotherapy and targeted treatments. The objective of this document is to review the literature and present consensus among a group of multidisciplinary experts to guide the determination of resectability and management of locally advanced non-small cell lung cancer (NSCLC) in the context of contemporary evidence.

Methods: The Society of Thoracic Surgeon Workforce on Thoracic Surgery assembled a multidisciplinary expert panel composed of thoracic surgeons and medical and radiation oncologists with established expertise in the management of lung cancer. A focused literature review was performed, and expert consensus statements were developed using a modified Delphi process to address 3 major themes: (1) assessing resectability and multidisciplinary management of locally advanced lung cancer, (2) neoadjuvant (including perioperative) therapy, and (3) adjuvant therapy.

Results: A consensus was reached on 19 recommendations. These consensus statements reflect updated insights on resectability and multidisciplinary management of locally advanced lung cancer based on the latest literature and current clinical experience, mainly focusing on the appropriateness of surgical therapy and emerging data regarding neoadjuvant and adjuvant therapies.

Conclusions: Despite the complex decision-making process in managing locally advanced lung cancer, this expert panel agreed on several key recommendations. This document provides guidance for thoracic surgeons and other medical professionals in the optimal management of locally advanced lung cancer based on the most updated evidence and literature.

Background: We investigated factors associated with the longitudinal presence of neurodevelopmental delays in pediatric heart transplant recipients.

Methods: The United Network for Organ Sharing Registry was queried for patients aged <18 years who received a first-time isolated heart transplant between March 2008 and December 2022. Two patient cohorts were developed, those with and without (1) definitive motor delay (MD) and (2) definitive cognitive delay (CD).

Results: The MD cohort was comprised of 3847 patients (n = 3267 [no MD], n = 580 [definitive MD]) and the CD cohort was comprised of 3446 patients (n = 2689 [no CD], n = 757 [definitive CD]). The MD cohort and the CD cohort shared 3189 patients. Compared with the intracohort nondelayed patients, definitive MD and CD cohorts each independently had higher rates of congenital heart disease, ventilator support at transplant, and stroke before discharge (P < .001 for all). Patients with a definitive delay at follow-up had worse longitudinal survival, with hazard ratios of 2.82 (95% CI, 2.32-3.44; P < .001) for the MD cohort and 1.67 (95% CI, 1.32-2.05; P < .001) for the CD cohort. Stroke before discharge and symptomatic cerebrovascular disease at listing were both predictors of CD and MD at follow-up. The definitive MD and CD cohorts each independently had higher rates of stroke before discharge (MD cohort, 57 of 580 [9.8%] vs 48 of 3267 [1.5%]; CD cohort, 53 of 757 [7.0%] vs 42 of 2689 [1.6%]; P < .001 for both), and symptomatic cerebrovascular disease at listing was a predictor of CD (odds ratio, 4.16; 95% CI, 2.62-6.58) and MD (odds ratio, 3.30; 95% CI, 2.06-5.22) at follow-up.

Conclusions: Patients with MD and/or CD after receiving a heart transplant share several characteristics, including increased stroke before discharge, and have decreased longitudinal survival compared with their nondelayed counterparts.

Background: In the early 2000s, a significant shortage of cardiothoracic surgeons was predicted. We sought to evaluate our specialty's progress and to update the predicted needs of cardiothoracic surgeons in the coming decades.

Methods: To assess the supply of cardiothoracic surgeons, the evolution of cardiothoracic surgery training was reviewed. The cardiothoracic surgery workforce and future supply and demand were obtained from the National Center for Health Workforce Analysis. Based on these data, predictions from the early 2000s were compared with the current status, and future supply of cardiothoracic surgeons was modeled.

Results: The number of cardiothoracic surgery trainees increased from 230 in 2008-2009 to 519 in 2022-2023. In 2022-2023, 174 trainees underwent the American Board of Thoracic Surgery Certification Exam, with 129 certificates awarded. From 2005 to 2021, the total number of practicing cardiothoracic surgeons in the United States increased from 4000 to 5200, which contradicts all projections from the early 2000s. The average attrition of 31 cardiothoracic surgeons per year was significantly less than predictive models from the early 2000s. Predictive models project a need of 7000 cardiothoracic surgeons by 2050, which can be met if we continue to fill our available training spots with 173 graduates per year.

Conclusions: The predicted shortage of cardiothoracic surgeons by midcentury has been overcome by training more cardiothoracic surgeons as well as by a reduction in cardiothoracic surgeon attrition. Future increasing demand can be met by filling our available training positions. Continual assessment of cardiothoracic surgeon supply and demand will help achieve the optimal number of cardiothoracic surgery training positions.

Background: We aimed to assess the impact of complex mitral valve disease and patient risk profile on operative outcomes in the large cohort of the Mini-Mitral International Registry.

Methods: Patients were assigned to categories of complex degenerative mitral valve regurgitation (DMR; bileaflet or anterior mitral leaflet prolapse/flail) and simple DMR (posterior mitral leaflet prolapse/flail). Subgroup analyses was performed in low-risk (EuroSCORE II <8%) and high-risk (EuroSCORE II >8%) cohorts. A logistic regression model was applied to investigate the impact of valve anatomy and patient risk factors on valve repair rate and operative risk.

Results: The study cohort consisted of 4524 patients with DMR (complex DMR, 1296; simple DMR, 3228). Valve repair rate was 87.3% and 91% in complex DMR and simple DMR, respectively. Predictors of valve replacement were anterior leaflet prolapse/flail, bileaflet flail, female sex, age, and reoperation, whereas Barlow disease was protective. Clinical results were comparable between complex DMR and simple DMR. On subgroup analyses, high-risk patients showed less satisfactory outcomes with respect to both the valve repair and operative mortality rates.

Conclusions: Our findings suggest that complex DMR can be satisfactorily addressed by minimally invasive techniques. However, whereas complex disease was associated with low operative risk, anterior leaflet lesions and bileaflet flail remain negative predictors of successful valve repair. Conversely, valve repair rate was less satisfactory in high-risk patients, regardless of DMR complexity.