Interdisciplinary cardiovascular and thoracic surgery最新文献

Objectives: The Association between preoperative D-dimer with morphologic features and surgical outcomes of Acute Type A Aortic Dissection (ATAAD) is still unclear.

Methods: 430 ATAAD patients who underwent total arch replacement (TAR) and frozen elephant trunk (FET) in Beijing Anzhen Hospital of Capital Medical University between January 2016 to December 2020 were enrolled in the present study. Patients were divided into higher D-dimer (>2307 ng/ml) group and lower D-dimer (≤2307 ng/ml) group. We compared the extent of dissection and branch artery perfusion patterns between the two groups. The restricted cubic spline (RCS) was performed to assess the association between D-dimer with the extent of dissection and major adverse events after surgery.

Results: Among 430 patients, there was 45(10.47%) in-hospital mortality and 156(36.28%) major adverse events. Patients with higher D-dimer had bigger dissection extension length and false lumen perimeter in ascending aorta, thoracic descending aorta, diaphragmatic, coeliac trunk, and renal artery level. For the branch artery perfusion patterns, Patients with higher D-dimer had a higher proportion of malperfusion among the innominate artery, right renal artery, and both side iliac artery, a higher proportion of dissected intercostal artery/all intercostal artery>0.5(43.46% vs 29.63%, p = 0.003). The RCS linear regression model revealed a nonlinear association between lnD-dimer with extension length and false lumen perimeter (all p for overall and p for nonlinearity＜0.001 except false lumen perimeter in ascending aorta level). The RCS logistic regression model revealed a linear association between lnD-dimer with major adverse events (p for overall＜0.001, p for nonlinearity = 0.637). The association between lnD-dimer and major adverse events was still significant in the fully adjusted logistic regression model with CTA characteristics (OR (95% CI) =1.388 (1.137, 1.695), p = 0.001).

Conclusions: Preoperative D-dimer strongly and positively correlates with the extent of dissection and major adverse events of ATAAD after total arch replacement (TAR) and frozen elephant trunk (FET). D-dimer seems to be a supplement that Indicates the severity of aortic dissection to aortic CTA.

We report a case of superior trunk brachial plexus injury following a right mini-thoracotomy mitral valve repair. A 45-year-old woman with systemic lupus erythematosus, who was on steroids and immunosuppressive drugs, underwent mitral valve repair via right mini-thoracotomy. The patient was positioned in the left semisagital position with the right upper arm elevated. Postoperatively, she exhibited focal motor and sensory deficits in the right upper extremity, and a superior trunk brachial plexus injury (BPI) on the right side was diagnosed through brachial plexus MRI and electrophysiological examination. The nerve injury was likely due to excessive left lateral flexion of the head during the procedure. Sensation returned to normal 4 weeks postoperatively, and muscle strength fully recovered 3 months postoperatively. Careful attention to positioning during minimally invasive cardiac surgery is crucial to prevent nerve compression in superficial areas and excessive lateral flexion of the head.

Objectives: This study aims to identify causes of failure in Fontan patients with a total cavopulmonary connection.

Methods: We conducted a comprehensive review of all patients who underwent a total cavopulmonary connection procedure at our centre between 1988 and 2023, aiming to identify and analyze the factors contributing to Fontan failure (defined as mortality, heart transplantation, Fontan takedown, protein-losing enteropathy, plastic bronchitis, or New York Heart Association Functional Classification class III or IV).

Results: The study included 217 patients (median age at time of Fontan completion 3.7 years) with a median follow-up of 12.7 years (IQR, 7.2; 17.7). Systolic ventricular function decreased significantly over time in patients with right ventricular dominant morphology (P = 0.002), while systolic ventricular function remained stable in patients with left ventricular dominant morphology. Fontan failure occurred in 24 patients, with estimated freedom from Fontan failure rates of 97.7% (95% CI, 95-99) at 1 year, 93.9% (95% CI, 89-97) at 15 years and 77.2% (95% CI, 65-86) at 20 years follow-up. Systolic ventricular dysfunction was the most common cause of failure (29%), followed by atrioventricular valve regurgitation (16.7%), a high pulmonary vascular resistance (16.7%), restrictive pathophysiology (16.7%) and obstruction (12.5%). Patients with right ventricular dominance developed most often systolic ventricular dysfunction, while patients with left ventricular dominant morphology developed most often restrictive pathophysiology or a high pulmonary vascular resistance.

Conclusions: Approximately 10% of patients experienced Fontan failure within 15 years postoperatively. Patients with right ventricular dominance experienced progressive decline due to systolic dysfunction, while those with left ventricular dominance exhibited failure due to restrictive pathophysiology or high pulmonary vascular resistance.

Objectives: Analysis of the long-term risks of ischaemic stroke and cerebral bleeding in patients with atrial fibrillation after mitral valve surgery and concomitant Cox-maze IV procedure.

Methods: In total, 397 patients with symptomatic degenerative mitral valve insuffciency and atrial fibrillation, underwent mitral valve surgery and Cox-maze IV in Sweden between 2009-2017. In this retrospective nationwide analysis, patients were followed in national patient registers until September 30, 2022.

Results: There were four deaths within 30 days (1.0%). Mean follow-up was 8.7 (0.1-13.4) years. Survival without ischaemic stroke or cerebral Haemorrhage at five and ten years were 90% and 74%, respectively. Nineteen patients experienced an ischaemic stroke, of which four were fatal. Five of 34 patients (14.7%) with a history of stroke preoperatively experienced ischaemic stroke during follow-up. The linearized rate of ischaemic stroke per patient-year was 0.6% and was similar regardless of left atrial appendage closure during surgery or whether a mechanical valve was inserted. The observed ischaemic stroke rate was lower than the predicted rate for all CHA2DS2-VASc score groups. Fourteen patients suffered cerebral bleeding, of which three were fatal. Patients who experienced cerebral bleeding were older, and had higher mechanical valve implantation rate than those without cerebral bleeding.

Conclusions: Surgery for mitral valve insufficiency and concomitant Cox-maze IV can be performed with low perioperative risk. There is a low continuing risk of stroke long-term postoperatively that correlates with higher CHA2DS2-VASc score. Patients with preoperative stroke are at increased risk of postoperative stroke despite atrial fibrillation surgery.

We describe a world-first robotic ablation for inappropriate sinus tachycardia. A 26-year-old woman with refractory inappropriate sinus tachycardia underwent robotic-enhanced hybrid ablation, combining electrophysiological mapping with superior visualization and access compared to VATS approaches. Ablations normalized the heart rate from 120 to 70bpm. One month later, she reported symptom resolution and improved quality of life. Holter monitoring confirmed no tachycardic episodes. This presents a promising alternative for patients who have exhausted conventional treatments, potentially revolutionizing IST management.

Objectives: This single-centre study compared the perioperative outcomes after total arterial multivessel revascularization through endoscopic-assisted, minimally invasive surgery compared to a conventional sternotomy approach.

Methods: In this retrospective, propensity score-matched (PSM) cohort study, a total of 740 patients were analysed [endoscopic coronary artery bypass grafting (Endo-CAB), N = 92; Sternotomy, N = 648]. After PSM (1:2 ratio), 73 Endo-CAB and 137 sternotomy patients were compared with an equal number of distal anastomoses (Endo-CAB 2.3 versus Sternotomy 2.4 anastomoses per patient, P = 0.082). We used 'textbook outcome' as a patient-orientated outcome measure, defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischaemia, cardiac tamponade, cerebrovascular events, wound infection, new onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (>7 days).

Results: Patients undergoing Endo-CAB had significantly more often a textbook outcome compared to the sternotomy group (78.1% vs 59.1%, P = 0.009). Endo-CAB patients had shorter hospital stay (4.0 vs 6.0 days, P < 0.001), less postoperative blood loss (360 vs 490 ml, P < 0.001) and a significant reduction of new onset postoperative atrial fibrillation (5.5% vs 17.5%, P = 0.015). Other postoperative outcomes were comparable for both groups.

Conclusions: Total arterial Endo-CAB demonstrates excellent postoperative outcomes compared to a sternotomy approach for multivessel coronary artery disease. These findings provide a strong basis for further expanding the multivessel Endo-CAB programme.

Transcatheter aortic valve replacement (TAVR) has become an established alternative to surgical aortic valve replacement for severe aortic stenosis. However, the long-term outcomes and need for surgical reintervention following TAVR remain uncertain. This case report describes a 76-year-old woman who underwent surgical explantation of a SAPIEN-XT valve more than a decade after initial TAVR implantation due to late valve failure. The patient presented with severe aortic insufficiency and heart failure symptoms. Surgical intervention involved concomitant ascending aortic replacement, tricuspid annuloplasty and coronary artery bypass grafting. The TAVR valve was successfully explanted using careful blunt dissection to avoid annulus damage. Postoperative recovery was uneventful, with the patient discharged after 4 weeks. This case highlights the potential need for long-term surgical management of patients after TAVR and emphasizes the importance of surgical preparedness as TAVR indications expand. It also provides valuable insights for surgeons encountering similar cases of late TAVR failure requiring explantation.

Objectives: Haemodynamic determinants of the ratio between pulmonary and systemic flow (Qp/Qs) in partial anomalous pulmonary venous return (PAPVR) are still not fully understood. Indeed, among patients with the same number of lung segments draining anomalously, a great variability is observed in terms of right ventricular overload. The aim of this study was to test the hypothesis that the anatomic site of drainage, affecting the total circuit impedance, independently influences the magnitude of shunt estimated by Qp/Qs. A zero-dimensional lumped parameter mathematical model was developed and validated on a sample of patients.

Methods: We developed a zero-dimensional lumped parameter model, using time-varying elastances for heart chambers, RLC Windkessel circuits for the systemic and pulmonary circulations. Patients were categorized into vena cava (VC) type (including left drainage to anomalous vein) and right atrium (RA) type. The mathematical model is a system of ordinary differential equations that are numerically solved by means of the ode15s solver in the MATLAB environment.

Results: The model showed an increase of Qp/Qs with the increase of the number of anomalous veins. With the same number of anomalous veins, Qp/Qs was lower in patients with anomalous drainage to the VC as compared with RA. The validation sample consisted of 49 patients (27, 55% females). As predicted by the model, patients with PAPVR with VC type displayed a lower invasive and cardiac magnetic resonance Qp/Qs as compared with drainage to RA: 1.4 (1.2-1.7) and 1.45 (1.25-1.6) versus 2 (1.75-2.1) and 1.9 (1.6-2), P < 0.05. After stratifying for number of lung territories, a lower Qp/Qs was measured in patients with VC PAPVR as compared with RA.

Conclusions: In patients with PAPVR, the site of anomalous drainage modulates the Qp/Qs. According to the model, this effect is mediated by the post-capillary impedance of the circuit and significantly decreases with the increase of pulmonary vascular resistances.

Persistent chylothorax is a major challenge in paediatric patients. We present a case of a 6.5 kg, 1-year-old boy with superior vena cava syndrome and persistent chylothorax who underwent successful surgery without cardiopulmonary bypass. His medical history included multiple comorbidities such as myeloproliferative disease, short bowel syndrome and central vein catheterizations. The patient also had innominate vein thrombosis, progressing to superior vena cava, and was on anticoagulants. Despite dietary changes and somatostatin, his high-output chylous pleural effusion persisted. He was treated with innominate vein-to-right atrial bypass using a 6-mm Dacron graft. Postoperatively, there was a significant reduction in effusion and accelerated recovery. Somatostatin failure was likely due to mechanical obstruction of the thoracic duct.