Annals of Thoracic Surgery最新文献

Background: The adoption of the robotic platform in thoracic surgery has increased within the last decade. We aim to compare clinical outcomes among facilities who performed lung resections for patients with non-small lung cancer (NSCLC) pre- and post-adoption of robotic surgery.

Methods: A retrospective case-control analysis was conducted utilizing the National Cancer Database from 2010-2021. Facilities that performed >/=90% of robotic lung resections for at least 2 consecutive years in 2016 or afterwards were deemed sustained adopters. Time periods for facilities were categorized by pre-transition (<50% usage), transition (50-90%) and post-transition (>/= 90%). Primary (30- and 90-day mortality) and secondary outcomes (30-day readmission, robot-to-open conversion, margin positivity, mean lymph nodes sampled, pathological upstaging) were analyzed pre- and post-adoption.

Results: Within our cohort, 57 facilities met criteria with 24,909 cases. Of these, 12,181 occurred in the pre-transition period (robotic usage [RU]8.6%), 7,440 in the transition period (RU 79.6%), and 5,288 in the post-transition period (RU 93.6%). Compared to control facilities, a greater proportion of study facilities experienced decreases in 30-day (70% vs 63.2%) and 90-day mortality (72.5% vs 52.6%) post-transition. A smaller proportion of study facilities showed decreases in mean lymph nodes sampled (17.5% vs 38.2%) and pathological upstaging (23.2% vs 40.7%) compared to control facilities.

Conclusions: Facilities who sustained adopted robotic surgery may be associated with decreased short-term mortality rates and higher rates of lymph nodes sampled and pathological upstaging. Continued uptake of robotic platforms in thoracic surgery is not only safe but may provide mortality and oncologic benefit.

Background: Aortic valve repair is preferred for congenital aortic valve disease in children, but its durability is limited. Although acceptable immediate repair results improve outcomes, late failures still occur. This study aimed to identify risk factors for suboptimal outcomes after an initially acceptable repair.

Methods: We retrospectively reviewed 287 patients undergoing primary aortic valve repair (2014-2023). Acceptable repair was defined as less than moderate aortic stenosis (AS) and mild or less aortic insufficiency (AI) after bypass. Suboptimal outcomes were defined as more than moderate AS/AI or reintervention after discharge. Cox analysis identified predictors among patients with acceptable repair, with a nomogram developed for pure AS patients.

Results: Median age at repair was 3.5 years (interquartile range, 1.0-8.1 years). Acceptable repair was achieved in 183 of 287 (64%). Median follow-up was 2.5 years (interquartile range, 0.7-4.7 years). Acceptable repair yielded superior 4-year freedom from suboptimal outcomes vs residual lesions (75% vs 51%, P < .001). Among 121 pure AS patients with acceptable repair, independent predictors for suboptimal outcomes were smaller preoperative annulus z-score (hazard ratio [HR], 0.69; P = .007), higher preoperative peak gradient (HR, 1.02; P = .034), and prior balloon aortic valvuloplasty (HR, 5.92, P < .001). The nomogram showed good discrimination (C index = 0.78). For mixed/pure AI patients, leaflet extension/augmentation was associated with suboptimal outcomes on univariate but not multivariable analysis.

Conclusions: Acceptable initial repair is crucial but does not guarantee long-term success. Smaller annulus z-score, higher gradient, and prior balloon aortic valvuloplasty in pure AS independently predict subsequent valve failure despite adequate initial repair. These factors may aid risk stratification and inform surveillance intensity.

Background: Right ventricular (RV) function is frequently reduced after cardiac surgery, with persistent impairment associated with increased mortality. This study aimed to compare RV function after mitral valve repair through right minithoracotomy vs sternotomy.

Methods: In the UK Mini Mitral trial, patients were randomized to mitral valve repair through right minithoracotomy (small lateral pericardial incision) or sternotomy. Prespecified secondary outcomes included assessment of cardiac function by blinded echocardiography preoperatively and at early (12 weeks) and late (52 weeks) time points. RV function was assessed by tricuspid annular plane systolic excursion (TAPSE). RV to pulmonary artery coupling was determined by the TAPSE to systolic pulmonary artery pressure ratio.

Results: Of 330 patients randomized, 224 had suitable echocardiographic data for analysis. Baseline demographic, clinical, and echocardiographic data were comparable between groups. Cross-clamp and bypass times were significantly longer in the minithoracotomy group. At 12 weeks, there was a significant reduction in TAPSE from baseline in both groups (TAPSE minithoracotomy, -7.52 mm [95% CI, -8.52 to -6.53; P < .001], vs sternotomy, -8.75 mm [95% CI, -9.80 to -7.71; P < .001]), which recovered, but not to preoperative levels, by 52 weeks. The degree of RV impairment was significantly less in the minithoracotomy group at both early (between-group difference in TAPSE at 12 weeks, 1.47 mm [95% CI, 0.37-2.56; P = .009]) and late time points (between-group difference in TAPSE at 52 weeks, 1.37 mm [95% CI, 0.29-2.45; P = .013]).

Conclusions: Despite longer cross-clamp and bypass times, mitral valve repair through minithoracotomy was superior to sternotomy at preserving RV function (measured by TAPSE) at 12 weeks and 1 year.