Annals of thoracic surgery short reports最新文献

Background

Single-ventricle cardiac defects (SVCDs) are among of the most health care resource–intensive congenital diseases. Although SVCDs are traditionally palliated using the Norwood pathway, in the last 2 decades select programs have used the hybrid strategy, which redistributes the operative and interstage risks. This study sought to characterize resource use for a cohort of patients with hybrid-palliated SVCD.

Methods

All patients with SVCDs who underwent palliation with the hybrid strategy and who were followed up exclusively at our institution from January 2008 to December 2021 were included. End points were death, Norwood conversion, orthotopic heart transplantation, 6 months post-Fontan status, or 4 years of age in those patients who had not completed staged palliation. Primary end points included total days hospitalized, number of cardiology visits, echocardiograms, catheterizations, and advanced imaging performed.

Results

Of 135 patients with a diagnosis of SVCD, 72 survived for 6 months after the Fontan procedure. By patient-year for the entirety of the pathway, patients had a median hospital length of stay of 16 days (interquartile range [IQR], 12-25 days), 7 cardiology visits (IQR, 6-9), 8 echocardiograms (IQR, 7-10), and 0.7 catheterizations (IQR, 0.4-1.1). The interstage 1 period had the heaviest resource burden requiring intense cardiology follow-up and echocardiography surveillance. Cardiac catheterizations and advanced imaging were most prevalent during interstage 2 period, with a median of 2 (IQR, 1-2) catheterizations and 36 (40%) patients undergoing advanced imaging. The total median number of hospital days per patient was 63 days (IQR, 47-98.5 days).

Conclusions

Resource use for the care of patients with SVCDs is significant. The intensity of surveillance decreases as patients progress through the pathway. In comparison with published Norwood pathway data, resource intensity and use patterns in hybrid palliation are comparable.

We present the case of a 41-year-old man with an anterior mediastinal mass and constellation of clinical symptoms, including dyspnea, pleural effusions, pericardial effusions, renal insufficiency, and pancytopenia. After inconclusive results on several laboratory tests and a nondiagnostic surgical biopsy specimen, a specimen from a second surgical biopsy identified the patient’s condition as Castleman disease associated with TAFRO (thrombocytopenia, anasarca, fevers, reticulin myelofibrosis, organomegaly) syndrome. This case highlights the importance of obtaining large tissue biopsy samples, interval follow-up, and acknowledging cognitive biases.

Dynamic chest radiography (DCR) is a novel radiographic technique that evaluates the thoracic movement from inspiration to expiration. Here, we report the efficacy of DCR in the surgical treatment of diaphragmatic paralysis. A 60-year-old woman presented with phrenic nerve palsy after anterior mediastinal resection. Subsequent dynamic chest radiography revealed left diaphragmatic paralysis with paradoxical movement of the bilateral diaphragms during breathing. We folded and sutured the flaccid left diaphragm through surgery. We evaluated the postoperative radiographic findings using DCR. Subsequent postoperative DCR revealed improvement in the left diaphragm paralysis with suppressed left lateral diaphragm displacement during breathing.

Aneurysms of the superior vena cava are rare vascular malformations of systemic veins. This report presents the case of a 27-year-old woman with an incidental finding of mediastinal shadow widening on the chest roentgenogram that was confirmed by computed tomographic angiography to be a superior vena cava saccular aneurysm >4 cm in diameter. Surgical resection was recommended on the basis of aneurysmal size and shape and was performed through median sternotomy by using cardiopulmonary bypass. The postoperative period was uneventful. During follow-up visits she remained asymptomatic. Saccular aneurysm surgery was recommended to prevent associated complications, including rupture, thrombosis, or venous obstruction.

Primary extraskeletal osteosarcoma of the lung is exceedingly rare and associated with a poor prognosis. This case report presents a patient with circumferential pulmonary ossification secondary to lung extraskeletal osteosarcoma with compressive mediastinal shift who underwent extrapleural pneumonectomy that led to resolution of symptoms. This case offers an approach to the operative management of primary thoracic osteosarcoma and suggests that even patients with advanced disease may be surgical candidates, particularly for symptom relief.

Background

Intraoperative physiologic parameters could offer predictive utility in evaluating risk of adverse postoperative events yet are not included in current standard risk models. This study examined whether the inclusion of continuous intraoperative data improved machine learning model predictions for multiple outcomes after coronary artery bypass grafting, including 30-day mortality, renal failure, reoperation, prolonged ventilation, and combined morbidity and mortality (MM).

Methods

The Society of Thoracic Surgeons (STS) database features and risk scores were combined with retrospectively gathered continuous intraoperative data from patients. Risk models were developed for each outcome by training a logistic regression classifier on intraoperative data using 5-fold cross-validation. STS risk scores were included as offset terms in the models.

Results

Compared with the STS Risk Calculator, models developed using a combination of the intraoperative features and the STS preoperative risk score had improved mean area under the receiver operating characteristic curve for prolonged ventilation (0.750 [95% CI, 0.690-0.809] vs 0.800 [95% CI, 0.750-0.851]) and MM (0.695 [95% CI, 0.644-0.746] vs 0.724 [95% CI, 0.673-0.775]). Additionally, models developed using intraoperative features had improved calibration, measured with Brier score, for prolonged ventilation (0.060 [95% CI, 0.050-0.070] vs 0.055 [95% CI, 0.045-0.065]) and MM (0.092 [95% CI, 0.081-0.103] vs 0.087 [95% CI, 0.075-0.098]).

Conclusions

The inclusion of time series intraoperative data in risk models may improve early postoperative care by identifying patients who require closer monitoring postoperatively.

We present the case of a 28-year-old female patient who underwent a bilateral lung transplantation for underlying terminal bronchopulmonary dysplasia. The peroperative access to the hilum of the right lung was significantly compromised due to the presence of a pectus excavatum (Haller index 11). We used a wired sternal crane technique to elevate the sternum and gain exposure. Release of the crane after implantation went smoothly, as did the postoperative recovery. This report illustrates the feasibility of this technique during lung transplantation.

Pulmonary artery intimal sarcoma has very poor prognosis, for which radical resection may be difficult. A 68-year-old man with pulmonary artery intimal sarcoma underwent bilateral pulmonary artery resection and replacement. At 31 months postoperatively, recurrence occurred at the anastomotic site of the right pulmonary artery. Therefore, he underwent right upper lobectomy and combined resection and reconstruction of the right pulmonary artery. The tumor was removed, while preserving the lungs as much as possible. He is still alive 42 months after the initial surgery.

Background

Current treatment guidelines for infective endocarditis focus on left-sided infective endocarditis. Because right-sided infective endocarditis has different presentations and outcomes, it is crucial to further delineate surgical outcomes for isolated tricuspid valve endocarditis (TVE).

Methods

This retrospective study reviewed 374 surgically treated patients with isolated TVE from January 2012 through April 2022 who underwent isolated tricuspid valve surgical procedures. Primary outcomes were in-hospital mortality, permanent pacemaker need, and postsurgical inotropic support.

Results

The in-hospital mortality was 4% (n = 15). Patients with liver disease had 3.81-times higher odds of death vs no liver disease (odds ratio [OR], 3.81; 95% CI, 1.22-12.17). A pacemaker was required in 17% of patients without a prior pacemaker, which was 4.07 times the odds with tricuspid valve replacement (OR, 4.07; 95% CI, 1.72-11.60) vs tricuspid valve repair. Each yearly increase in patient age demonstrated lower odds of permanent pacemaker requirement by 7% (OR, 0.93; 95% CI, 0.89-0.97). The odds for postoperative inotropic support increased 2.55-times higher in patients receiving preoperative inotropic agents (OR, 2.55; 95% CI, 1.29-5.05), 2.27-times higher with renal failure (OR, 2.27; 95% CI, 1.38-3.74), and 86% higher in patients administered preoperative heparin (OR, 1.86; 95% CI, 1.14-3.02).

Conclusions

Mortality of surgical treatment for TVE was 4%, with higher risks with liver disease. Tricuspid valve replacement was associated with higher odds for permanent pacemaker vs repair. Renal failure, preoperative inotropic support, and preoperative heparin were associated with higher odds for postoperative inotropic support. These findings further illustrate surgical outcomes with TVE.

Background

Understanding the development of central venous catheter-related thrombus (CVCRT) is vital for the prevention of adverse events caused by thrombi after cardiac surgery in children. However, the risks associated with CVCRT remain controversial. This study analyzed the risk factors of CVCRT based on a detailed evaluation of its morphometric features and severity.

Methods

Patients aged <15 years who underwent catheter insertion into the internal jugular vein for cardiac surgery were included, and those receiving extracorporeal membrane oxygenation were excluded. The clinical data of the eligible patients, including the ultrasound CVCRT images and the ratio of the catheter occupying the internal jugular vein area (C/V ratio) by reassuming the images, were consistently collected. Logistic regression analysis using clinical factors was performed for the 2 groups divided according to morphologic severity.

Results

Forty-seven patients were included in the study. CVCRT developed in 38 patients. Five graded types, ranging from wall-localized small thrombi to complete occlusion of the vein, were detected, and those who developed sheath-like thrombus were classified in to the severe group. Patients in the severe group were significantly younger and had higher C/V ratios. There were no significant differences in the surgical procedure, its difficulty, or postoperative severity score. Logistic regression analysis revealed the C/V ratio as the sole significant risk factor (odds ratio, 1.120; 95% CI, 1.01-1.24; P = .036).

Conclusions

Our findings show the clinical implications of thrombus evaluation and morphologic classification to properly assess the risk factors of CVCRT in children with heart disease.