Annals of Thoracic Surgery最新文献

Background: As the life expectancy of patients with Down syndrome (DS) improves, the number of older patients with DS who require a cardiac surgical procedure for congenital heart disease will increase. Perioperative risk factors and outcomes in these patients are unknown.

Methods: In a multicenter retrospective study, teenaged and adult patients with DS who underwent a cardiac surgical procedure between 2008 and 2018 were matched by age and surgical procedure with patients who did not have DS. Demographic, medical, and surgical characteristics were compared. Outcome measures were length of stay (LOS), duration of mechanical ventilation, need for noninvasive positive pressure ventilation and reintubation, additional cardiac interventions, postoperative infections, and early postoperative mortality. Risk factors for extended hospital LOS (>10 days) were explored using multivariable logistic regression.

Results: The study compared 121 patients with DS with 121 patients who did not have DS. Patients with DS had a longer median LOS (7 days vs 5 days; P < .001), a longer duration of mechanical ventilation (12.5 hours vs 6.7 hours; P < .001), greater need for noninvasive positive pressure ventilation or reintubation (26% vs 4%; P < .001), and a higher likelihood of postoperative infections (10% vs 2%; P = .035). There was no early mortality. Preoperative risk factors for extended LOS for patients with DS included pulmonary medication use (odds ratio [OR], 4.0; P = .046), a history of immunodeficiency (OR, 10.4; P = .004), or moderate or greater tricuspid regurgitation (OR, 12.7; P < .001).

Conclusions: Teenaged and adult patients with DS who underwent congenital a cardiac surgical procedure had a longer hospital LOS and more postoperative respiratory and infectious complications compared with patients who did not have DS, without increased mortality. A cardiac surgical procedure can be performed safely in older patients with DS. Management of pulmonary disease, immunodeficiency, and tricuspid regurgitation may mitigate risk.

Background: Previous studies defined complete revascularization as the placement of at least 1 bypass graft to each diseased coronary territory. This study was conducted to evaluate whether putting more than 1 graft to each diseased coronary territory is beneficial for patients with 3-vessel disease (3VD) who underwent coronary artery bypass grafting (CABG).

Methods: Among 1859 patients who underwent primary isolated CABG, 1008 patients (male-to-female ratio, 841:239; mean age, 67.0 ± 9.3 years) who underwent OPCAB for 3VD and in whom complete revascularization was achieved were retrospectively enrolled. Complete revascularization was defined as at least 1 graft to each coronary artery territory. The median follow-up duration was 86.6 months (interquartile range, 53.0-126.9).

Results: A total of 829 patients (82.2%) had more than 3 distal anastomoses, whereas the other 179 patients had 3 distal anastomoses. Hypertension (n = 729; 72.3%) and diabetes (n = 556; 55.2%) were the most common comorbidities without any intergroup differences. The early mortality rate was 1.0% (n = 10). Late death occurred in 337 of 998 early survivors. Five- and 10-year all-cause mortality rates were 18.0% and 36.0%, respectively. Cumulative incidences of cardiac deaths were 5.2% and 9.2%, respectively. The inverse probability treatment weighting-adjusted multivariate analyses showed that having more than 3 distal anastomoses was associated with lower all-cause mortality and cardiac death (hazard ratio, 0.76 [95% CI, 0.57-0.99] and hazard ratio, 0.50 [95% CI, 0.31-0.83], respectively).

Conclusions: Grafting more than 1 diseased vessel in each diseased coronary territory during CABG may be beneficial for patients with 3VD in terms of all-cause mortality and cardiac death.

Background: Mitral valve replacement in the setting of severe annular calcification (MAC) is associated with high morbidity and mortality. Direct surgical implantation of a transcatheter heart valve (THV) through a transatrial approach is a strategy to mitigate surgical risk. This study reports the perioperative and 1-year outcomes of mitral valve replacement using a THV in patients with severe circumferential MAC at 3 Canadian centers.

Methods: Charts were reviewed between January 1, 2018 and September 30, 2023 to identify patients with severe circumferential MAC who had undergone direct implantation of a THV. Primary outcomes were 30-day mortality, debilitating stroke, and 1-year mortality. Secondary outcomes included left ventricular outflow tract obstruction, degree of paravalvular leak (PVL), transvalvular mean pressure gradient, and length of stay.

Results: Twenty-two patients at the 3 centers underwent direct implantation of a THV. Nineteen patients were female, with mean age of 70.41 ± 9.33 years. A THV was successfully implanted in all patients. There were 2 deaths at 30 days. Four patients of noncardiac causes at 1 year, and 1 patient had a postoperative stroke. Seventeen (77%) patients had no PVL or trace PVL, 4 had mild PVL, and 1 patient had mild-moderate PVL. The mean transvalvular gradient was 4.42 ± 4.40 mm Hg. There were no cases of left ventricular outflow tract obstruction.

Conclusions: Direct deployment of a THV in patients with severe MAC may be a reasonable option. Thirty-day and 1-year mortality rates of 9% and 18%, respectively, suggest that this approach should be reserved for high-risk patients who are not able to undergo conventional strategies.

Background: The incidence and prognosis of aortoesophageal fistula (AEF) has not been clarified. The clinical characteristics and surgical outcomes of AEF were investigated.

Methods: The clinical data of patients who underwent surgical treatment of AEF from January 2020 to December 2021 that were registered in the Japan Cardiovascular Surgery Database (JCVSD) were analyzed.

Results: During the period, 123 patients (aged 71.0 years [interquartile range, 61.0-78.0 years]; 76.4% men) underwent surgical treatment of AEF. The prevalence of secondary AEF was 61%. Secondary AEF after aortic grafting was the most frequent (n = 40 [32.5%]), followed by AEF after thoracic endovascular aortic repair (TEVAR; n = 30 [24.4%]). Operative mortality occurred in 23 patients (18.7%). TEVAR for AEF (P = .019). Univariable logistic regression analyses showed postoperative bleeding (P = .047), stroke (P = .004), renal failure (P < .001), newly required hemodialysis (P = .023), pneumonia (P = .003), multisystem failure (P < .001), and dyslipidemia (P = .02) were associated with risk factors of operative mortality after surgical treatment of AEF.

Conclusions: This nationwide study on the surgical treatment of AEF demonstrated a higher incidence of secondary AEF than primary AEF. Open surgical repair and TEVAR for AEF were both associated with high operative mortality. TEVAR and dyslipidemia were risk factors for operative mortality. Precautions and further improved treatment strategies for AEF are still required.

Background: Transfers for cardiac surgery are not well studied. We sought to understand the risk profile of transferred patients and determine whether transfer rates vary by cardiac surgery and whether outcomes of transferred patients vary with type of referral hospital/surgery.

Methods: Patients undergoing cardiac surgery with operative risk models were identified from The Society of Thoracic Surgeons database between July 1, 2014, and December 31, 2022. Patients were stratified as no transfer, transferred from hospital with cardiac surgery, and transferred from hospital without cardiac surgery. Risk associated with transfer compared with no transfer was derived by using multivariable logistic regression for operative mortality and select perioperative outcomes.

Results: Included were 1,828,787 patients at 1145 hospitals, with 1,452,491 no-transfer patients (79.4%), 28,862 transfers (1.6%) from hospitals with cardiac surgery, and 347,434 transfers (19.0%) from hospitals without cardiac surgery. Most transferred patients underwent coronary artery bypass grafting (83.6%); however, transfers from hospitals with cardiac surgery were most common for mitral valve replacement (17.9%). Transferred patients had increased comorbid diseases and urgent/emergent procedures. In multivariable analysis, transfers from hospitals with/without cardiac surgery were not associated with differential risk of adverse outcomes by procedure type. Patients transferred from hospitals with cardiac surgery undergoing mitral and aortic valve replacement and coronary artery bypass grafting had significantly lower adjusted mortality risk compared with nontransferred patients, whereas composite morbidity/mortality was higher in mitral valve repair.

Conclusions: Patients transferred for cardiac surgery are generally higher risk; yet, outcomes at transfer to hospitals are as expected or better. However, further research is necessary to examine patients who are transferred but do not undergo surgery.