Annals of Thoracic Surgery最新文献

Background: It has long been held that the safe duration of hypothermic circulatory arrest (HCA) is at least 25 to 30 minutes. However, this belief is based primarily on clinical outcomes research and has not been systematically investigated using more sensitive brain imaging and neurocognitive assessments.

Methods: This exploratory substudy of the randomized Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest (GOT ICE) trial, which compared outcomes for deep vs moderate hypothermia during aortic arch surgery, investigated the frequency of neurocognitive and structural and functional magnetic resonance imaging (MRI) deficits with HCA of short (<20 minutes) duration. Neurocognitive deficit was defined as ≥1 SD decline in ≥1 of 5 cognitive domains on neurocognitive testing.

Results: Of 228 GOT ICE participants with complete 4-week cognitive data, 74.6% (n = 170 of 228) had HCA durations <20 minutes, including 59 patients randomized to deep hypothermia (<20.0 °C), 55 patients randomized to low-moderate (20.1-24.0 °C) hypothermia, and 56 randomized to high-moderate (24.1-28.0 °C) hypothermia. Of these participants, cognitive deficit was detected 4 weeks postoperatively in ∼40% of patients in all 3 groups (deep hypothermia, 22 of 59 [37.3%]; low-moderate hypothermia, 23 of 55 [41.8%]; and high-moderate hypothermia, 24 of 56 [42.9%]). Furthermore, in a subset of patients with complete MRI data (n = 43), baseline to 4-week postoperative right frontal lobe functional connectivity change was inversely associated with HCA duration (range, 8-17 minutes; P for familywise error rate < .01).

Conclusions: Even short durations of HCA result in cognitive deficits in ∼40% of patients, independent of systemic hypothermia temperature. HCA duration was inversely associated with frontal lobe functional MRI connectivity, a finding suggesting that this brain region may be preferentially sensitive to HCA. Surgeons should be aware that even short durations of HCA may not provide complete neuroprotection after aortic arch surgery.

Background: The characteristics of early-onset lung adenocarcinoma (EOLA) have not been extensively studied. Our research aimed to comprehensively assess the clinical and genetic features of EOLA.

Methods: We conducted a retrospective analysis of surgically resected lung adenocarcinoma patients, categorizing them into the EOLA group (aged <40 years) and the late-onset lung adenocarcinoma (LOLA) group (aged >60 years). A comparative investigation of clinical, germline, and genomic features was conducted. Propensity score matching was used to balance baseline characteristics for gene mutation analysis.

Results: We enrolled 487 EOLA and 2507 LOLA patients. EOLA patients exhibited a higher female-to-male ratio (2.55 vs 1.19) and a higher proportion of family history of lung cancer in the ground-grass opacity subgroup (12.7% vs 8.9%). The EOLA group exhibited higher rates of earlier stage in the ground-grass opacity subgroup and solid subgroup. Preinvasive adenocarcinoma was the dominant histologic subtype in the EOLA group within the ground-glass opacity subgroup (73.8% vs 25.6%). After propensity score matching, we analyzed 241 stage 0/I patients with available genetic test results. Significant disparities in gene mutation rates emerged between the EOLA and LOLA patients, including Erb-B2 receptor tyrosine kinase 2 (ERBB2; 38.0% vs 2.8%), epidermal growth factor receptor (EGFR; 36.0% vs 64.5%), MET (0.0% vs 7.1%), neurofibromin 1 (NF1; 0.0% vs. 5.7%), and anaplastic lymphoma kinase (ALK) fusion (10.0% vs 1.4%).

Conclusions: EOLA patients exhibited distinct clinical and genetic characteristics compared with LOLA patients.

Background: Anesthesia administered to a patient with a large mediastinal mass engenders concern that it may precipitate catastrophic acute hemodynamic or respiratory decompensation. A review of the available evidence is needed to define the degree of risk, mechanisms, and preventative or reactive interventions to mitigate the risk.

Methods: A systematic review of the PubMed database was conducted of studies involving adults with large mediastinal masses undergoing a procedure or anesthesia; all types of publications were included that provided data regarding risks, mechanisms, or techniques to address potential decompensation. This literature involves primarily case reports and small retrospective series; no quality assessment was deemed appropriate. Evidence was synthesized according to the consensus judgment of the writing panel.

Results: Categories of low-, moderate-, high-, and very-high-risk emerged from review of the 72 included studies, based on the degree of symptoms, mass/chest ratio, and degree of airway and/or vascular compression. This streamlines the preparation needed-minimal for low-risk and more extensive for higher-risk. Assessment of the impact of physiologic derangement stemming from the anatomic compression in individual patients provides a framework for anesthetic management, and back-up plans should decompensation occur.

Conclusions: Despite limitations in the evidence inherent to a topic involving an uncommon but serious event, a framework was developed to streamline preparation for and management of patients with a large mediastinal mass requiring anesthesia in a rational manner.

Background: The Single Ventricle Reconstruction (SVR) trial compared survival after Norwood procedure with either modified Blalock Taussig shunt (MBTS) or right ventricle pulmonary artery shunt (RVPAS).

Methods: Data from all 549 participants in the SVR trial were used to develop the MBTS TFSA algorithms, which predict the transplantation-free survival advantage (TFSA) after MBTS vs RVPAS at 1 and 6 years after Norwood procedure. Linear regression analysis of the MBTS TFSA values was performed to identify factors related to more optimal outcomes with MBTS at each timepoint. The impact of discordant management (ie, predicted shunt type did not equal the one actually received) on outcomes and the extent of inconsistencies between predictions were evaluated.

Results: The MBTS TFSA algorithm favored MBTS over RVPAS for only 6.2% of participants at 1 year and for 27.0% at 6 years. In terms of both 1- and 6-year outcomes, MBTS was favored with younger age at Norwood procedure and pre-Norwood intubation, while RVPAS was favored with younger gestational age and metrics indicating larger right ventricle size in the parasternal echocardiographic views. Other predictors were timepoint-specific. MBTS TFSA based allocation could have led to an absolute risk reduction in heart transplantation and mortality of 8.0% at 1 year and 16.8% at 6 years, mostly by preventing discordant MBTS management. Notably, separate predictions from the 1-year and 6-year algorithms produced discordant predictions for 136 participants (24.8%).

Conclusions: The incorporation of data-derived patient-specific factors for selection of shunt type for the Norwood procedure may produce more optimal transplantation free survival. These precision medicine algorithms require prospective validation.

Background: Bilateral internal thoracic artery (ITA) grafting is associated with improved long-term outcomes; however, the appropriate graft configuration remains controversial. We compared the long-term outcomes of different graft configurations.

Methods: Between 2009 and 2015, 1171 patients underwent isolated bilateral ITA grafting for left-sided complete revascularization at 4 Japanese cardiac surgery centers: underwent in situ left ITA to the left anterior descending artery plus in situ right ITA to the left circumflex artery (LR group, n = 278), in situ right ITA to the left anterior descending artery plus in situ left ITA to the left circumflex artery (RL group, n = 665), and in situ left ITA to the left anterior descending artery plus free right ITA to the left circumflex artery (free group, n = 228). Major adverse cardiovascular events (MACEs), including mortality, myocardial infarction and revascularization, and ITA patency, were compared.

Results: Among the 3 groups, the free group showed significantly lower MACEs and overall mortality rates (P < .001). Nonfatal myocardial infarction and revascularization rates showed no marked differences among the groups. A weighted analysis revealed a decreased risk of MACEs and death in the free group. No marked difference was observed in the patency of the ITA anastomosed to the left anterior descending artery. Patency of the ITA grafted to the circumflex artery in the LR group was significantly lower relative to the other groups. Using a free right ITA grafted to the circumflex artery reduced the risk of graft failure.

Conclusions: The free right ITA configuration for left-sided revascularization might have better long-term outcomes and significantly better patency than other grafts.