Interdisciplinary cardiovascular and thoracic surgery最新文献

Objectives: To assess short-term outcomes of coronary artery bypass grafting with adjunct coronary endarterectomy compared with isolated bypass grafting, and to synthesise available confounder-adjusted effect estimates.

Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines. MEDLINE, Embase, and CENTRAL were searched from January 2000 to June 2025. Eligible studies compared adult patients undergoing coronary artery bypass grafting with coronary endarterectomy versus isolated coronary artery bypass grafting. Two reviewers independently screened studies, extracted data, and assessed quality. Random-effects meta-analysis was performed. The primary outcome was 30-day or in-hospital mortality.

Results: Sixteen studies (119,458 patients) were included. Coronary artery bypass grafting with coronary endarterectomy was associated with higher mortality (RR 1.84, 95% CI 1.65-2.04). Pooling adjusted odds ratios from three studies yielded OR 1.76 (95% CI 1.55-2.00), with two of three individual estimates not reaching significance. Secondary outcomes showed increased risks of perioperative myocardial infarction (RR 1.99, 95% CI 1.29-3.07), stroke (RR 1.37, 95% CI 1.08-1.75), renal failure (RR 1.62, 95% CI 1.44-1.82), and intra-aortic balloon pump use (RR 1.96, 95% CI 1.41-2.70). Sensitivity analyses confirmed consistency across all subgroups.

Conclusions: Coronary artery bypass grafting with coronary endarterectomy is associated with higher short-term mortality and morbidity compared with isolated bypass grafting; however, confounder-adjusted analyses suggest this excess risk is partly attributable to greater baseline disease severity rather than an independent procedural effect. The scarcity of data and absence of randomized evidence preclude definitive causal conclusions. These findings provide benchmarking data for counselling when endarterectomy is necessary to achieve complete revascularisation.

Objectives: The increasing use of CT imaging and the implementation of lung cancer screening have led to a rising detection of pulmonary nodules. Accurate management requires reliable localization techniques enabling pathological diagnosis and potential curative resection. This study compared hook-wire localization and cone-beam computed tomography (CBCT)-guided detection in terms of diagnostic yield.

Methods: A retrospective analysis was performed in two French academic centers including 260 patients with 266 nodules (January 2012-May 2019). The primary end-point was diagnostic yield, defined as the proportion of successfully localized nodules. Secondary end-points included localization and operative times, peri- and postoperative complications, chest tube duration, and hospital stay.

Results: Diagnostic yield was 88.0% with hook-wire localization and 96.9% with CBCT, corresponding to an absolute difference of 8.9% (95% confidence interval: -0.2 to 17.9; p = 0.053). Complication rates (p = 0.63), drainage duration (p = 0.13), and hospital stay (p = 0.16) did not differ between groups. Operative time (p = 0.042) and localization time (p = 0.001) were significantly longer with CBCT and hook-wire respectively.

Conclusions: Hook-wire and CBCT localization demonstrated comparable diagnostic yields and acceptable safety profiles. CBCT required longer operative room utilization, whereas hook-wire placement was performed in the radiology department, saving resources for other surgeries.

Unguarded tricuspid orifice is a rare anomaly of the tricuspid valve characterized by complete absence of tricuspid valve tissue and chordae on a proportion of the annulus. Management strategies vary widely. We report a case of successful repair of an unguarded tricuspid orifice with a simplified technique. A 35-year-old male presented with severe tricuspid regurgitation and right ventricular volume overload. Intraoperative inspection of the valve revealed an unguarded tricuspid orifice. For repair, sliding plasty of anterior and posterior leaflets were performed, followed by ring annuloplasty and commissuroplasty. Postoperative, echocardiogram showed minimal residual tricuspid regurgitation and significantly improved right ventricular dimensions. This case highlights the possibility of successful repair of an unguarded tricuspid orifice. If feasible, repair can be a good choice.

Objectives: Abdominal aortic aneurysm (AAA) is often fatal when ruptured and current guidelines suggest surgical management at suprathreshold sizes (50 mm for women or 55 mm for men) or with rapid expansion (>5 mm/year). Many medical therapies have been assessed for reducing subthreshold AAA expansion though the evidence remains inconclusive. This network meta-analysis (NMA) compares AAA growth and mortality amongst medical treatments for AAAs.

Methods: MEDLINE (via PubMed), Scopus, Web of Science, EBSCO, and Cochrane Library databases were searched for relevant randomized controlled trials (RCTs) from database inception to 2024. Outcomes assessed included AAA growth rate, rate of referral for aneurysm surgery, overall mortality, and discontinuation from adverse effects. Data was analyzed using R software, and P-score was used to rank different treatments. The GRADE framework was performed to assess quality of evidence.

Results: Thirteen RCTs comprising 3084 patients were included in this NMA. AAA diameters ranged from 3.1-4.6 cm in the intervention group and 3.5-4.5 cm in the placebo group. Study-level mean annual growth rate ranged from 1.2-2.8 mm/year in the intervention group compared with placebo (1.2-2.6 mm/year). There were no significant differences in AAA growth among the compared groups, (P-score probability in brackets): propranolol (0.73) telmisartan (0.66), antibiotics (0.53), placebo (0.53), ACE inhibitors (0.52), ticagrelor (0.46), and pemirolast (0.06). There were no significant differences among the compared groups in terms of aneurysm surgery referral rates, with propranolol (0.91), antibiotics (0.56), placebo (0.45), and pemirolast (0.08) showing similar outcomes. Similarly, no significant differences were observed in overall mortality rates across the groups, including telmisartan (0.87), antibiotics (0.57), ACE inhibitors (0.51), placebo (0.35), and propranolol (0.17). However, propranolol (OR = 3.14, 95% CI [1.34, 7.35]) and ticagrelor (OR = 5.10, 95% CI [1.12, 23.18]) were associated with a higher rate of discontinuation due to adverse events. Most of the studies analysed demonstrate moderate quality evidence.

Conclusions: Current evidence highlights ongoing uncertainty regarding the efficacy of medical therapies in reducing subthreshold AAA growth rates, rates of referral for surgical repair, or overall mortality. The absence of statistically significant benefit may reflect underpowered datasets rather than definitive treatment inefficacy. Future large-scale, appropriately powered randomized controlled trials evaluating emerging medical treatments are required to accurately assess their clinical potential.

The right top pulmonary vein (RTPV) is a rare venous anomaly arising from the posterior segmental vein, which runs dorsal to the bronchus intermedius. This anatomy increases the risk of vascular injury during right lower lobectomy, particularly during subcarinal lymph node dissection and fissure division. We describe thoracoscopic right lower lobectomy with subcarinal lymph node dissection in a patient with RTPV. Key techniques include circumferential dissection of the RTPV and a fissure-last technique. This case highlights practical strategies for preserving anomalous veins and enabling safe subcarinal lymph node dissection, contributing to technically reproducible thoracoscopic surgery.

Objectives: Cardiac surgery demands substantial technical skill and intraoperative judgement. Residents must develop operative autonomy in preparation for independent consultant practice. However, current challenges, including working hour restrictions, shorter training programmes, reduced operative exposure, and increasing case complexity, limit opportunities for skill development. This study evaluated the safety of "truly autonomous" cardiac surgery performed by senior residents without direct consultant supervision.

Methods: Data for all adult cardiac surgeries between January 2015 and December 2024 were extracted from our institutional database. All resident-led cases undertaken without direct consultant supervision (Group R) were identified and 1:1 propensity-score matched with consultant-led cases (Group C) using the EuroSCORE II covariates. In-hospital outcomes (mortality, complications, length of stay) and long-term survival were compared.

Results: 16,945 procedures were undertaken during the study period. After applying inclusion/exclusion criteria, matching yielded 803 pairs, giving a study population of 1,606 patients. Groups had comparable demographics, preoperative characteristics, risk scores and bypass/cross-clamp times. Consultants undertook significantly more combined/aortic cases, with residents performing more isolated CABG/valve procedures. Groups had similar in-hospital outcomes and long-term survival. In a subgroup analysis of emergency operating, groups had similar outcomes.

Conclusions: Truly autonomous cardiac surgery by senior residents demonstrated comparable in-hospital and post-discharge outcomes to consultant-led cases. Even in emergency procedures, senior residents achieved comparable outcomes to matched consultant-led cases. Our study shows truly autonomous operating in appropriately selected cases to be feasible and safe, providing evidence-based justification for progressive independence in cardiac surgical training.

This study reported the preliminary analysis of a Phase II prospective, double‑blind, randomized controlled trial that tested the Early Supervised Incremental Resistance Training (ESpIRiT) intervention following median sternotomy, and explored its effects on upper limb function and patient‑reported pain at four weeks and three months. Primary outcomes were safety(defined by sternal wound complications); feasibility(assessed by recruitment and adherence; and upper limb function measured by the Unsupported Upper Limb Exercise Test(UULEX). Secondary outcomes included the Functional Difficulty Questionnaire Shortened Version(FDQ‑s) and pain using the Numeric Rating Scale(NSR). Assessments occurred at baseline, discharge, four weeks, and three months postoperatively. Fifty‑five participants were recruited(ESpIRiT n = 27; standard care n = 28). No sternal complications occurred(RR 0.963, 95% CI 0.057-16.21). Adherence was 80%, with no dropouts. Between‑group differences in UULEX were not significant at four weeks(MD 1.49, 95% CI -4.62 to 7.16) or three months(MD 1.19, 95% CI -5.58 to 7.79). No significant differences were found for FDQ‑s or NSR. Within‑group analyses showed significant improvements in UULEX, FDQ‑s, and NSR over time. ESpIRiT was safe, feasible, and well‑accepted in the acute inpatient setting, with strong recruitment, adherence, and no adverse events. Trial registration: ISRCTN 17842822, registered 11 March 2020.

Coronary artery abnormalities (CAAs) are frequently encountered in common arterial trunk (CAT), with an estimated incidence of 5-20%. However, their prognostic implications remain unclear. Surgical challenges potentially arise due to coronary arteries crossing the right ventricular outflow tract (RVOT), close proximity of the coronary and pulmonary orifices, and distortion to the proximal coronary segments and ostia during arch reconstruction or truncal valve replacement. Some studies have demonstrated that CAAs confer worse outcomes after CAT repair, while others have reported no significant prognostic impact. Both the number and subtype of CAAs may influence outcomes, but heterogeneous categorisation limits the conclusions that can be drawn from existing studies. A uniform classification of CAAs in CAT is warranted to better ascertain the prognostic impact of CAA burden and morphology. This may enable more focused decision-making in clinical scenarios where a high-risk CAA pattern is suspected. For example, it may help inform the intraoperative trade-off between probing the coronaries to define their precise morphology against the risk of causing damage. We propose a classification consisting of six abnormalities: A) single coronary artery, B) ostial stenosis, C) intramural course, D) juxtacommissural origin, E) coronary crossing RVOT, and F) close proximity of coronary and pulmonary orifices.

Objectives: Postoperative pain remains a discomfort for patients undergoing thoracic surgery despite advances in minimally invasive techniques. Pulsed radiofrequency is a minimally invasive neuromodulation method used for chronic pain. This pilot study aimed to evaluate the efficacy of intraoperative PRF (iPRF) as an adjunct to conventional analgesia (thoracic epidural analgesia [TEA] or intercostal nerve block [INB]) in alleviating postoperative pain and analgesic use following minimally invasive thoracic surgery.

Methods: A prospective pilot cohort was compared with historical controls at a single tertiary hospital in Japan. The iPRF group (n = 30) received PRF targeting the intercostal nerves intraoperatively in addition to standard analgesia. The control group comprised retrospective patients who received standard analgesia alone. Patients were stratified into TEA and INB subgroups according to procedure type. The primary end-point was the proportion of patients requiring additional analgesics. Secondary end-points included pain scores (numerical rating scale [NRS]), incidence of intercostal neuralgia, and side effects.

Results: iPRF significantly reduced the need for additional analgesics in TEA (26.7% vs 60.0%, P = 0.027) and INB (6.7% vs 42.1, P = 0.020) subgroups. In the TEA group, iPRF also reduced the proportion of patients reporting NRS ≥4 following drain removal (26.7% vs 60.0%, P = 0.027). The incidence of analgesic-induced side effects was significantly lower in the iPRF INB group (0% vs 28.6%, P = 0.031). No adverse events were associated with iPRF.

Conclusions: iPRF may be a safe and effective adjunctive method for postoperative pain alleviation in thoracic surgery, reducing analgesic requirements.