Interdisciplinary cardiovascular and thoracic surgery最新文献

Objectives: The high intubation rate due to COVID-19 infection has increased the prevalence of post-intubation tracheal stenosis (PITS). We aimed to compare PITS induced by COVID-19 infection with PITS from non-COVID-19 etiologies.

Methods: This cohort study utilized PITS data collected prospectively between January 2018 and May 2023. 337 PITS patients were identified and those with direct neck trauma, burn inhalation injuries, and a prior history of tracheal surgery were excluded. Sixty-one COVID-19-related (CR) and 243 non-COVID-19-related (NCR) patients were compared before and after Propensity Score Matching (PSM) including demographics, comorbidities, intubation duration, clinical presentation, stenosis characteristics, the need for resectional airway surgery, and outcomes.

Results: Before matching, CR patients were older, more diabetic, less smoker, and they experienced longer intubation durations. After PSM, 59 CR and 59 NCR PITS patients, were included for comparison.Although no statistically significant differences were observed in stenosis, CR PITS patients required significantly more airway resection (81.4%) for definitive management than NCR (42.4%), P-value < 0.001. Postoperative complications, recurrence, and outcomes revealed no significant differences after PSM.

Conclusions: Given the increased need for surgical resection in CR PITS patients, thoracic surgeons should consider the increased likelihood of conservative therapy failure in them. Considering this finding and that no statistically significant difference was observed in postoperative outcomes in our study, we recommend a sooner decision for resectional airway surgery in CR than NCR PITS patients.

This case report presents a instance of pleural epithelioid hemangioendothelioma (EHE), a vascular tumour with an incidence of less than 1% among vascular tumors. The patient, a 43-year-old man, presented with a right-sided pleural effusion, longstanding neck and shoulder pain, and worsening pleuritic chest pain. Initial imaging revealed a left infra-clavicular soft tissue mass, pleural thickening, and pulmonary nodules suggestive of metastases. Despite inconclusive initial biopsies, immunohistochemistry and an international pathology review confirmed EHE, characterised by CAMTA1 expression and WWTR1 CAMTA1 fusion. The pleural involvement indicated metastatic disease, leading to a poor prognosis. Treatment with the MEK inhibitor trametinib was initiated, but the patient died within three months. This case underscores the diagnostic challenges of EHE due to its rarity and variable clinical presentation, which often delays diagnosis until advanced stages. The report highlights the aggressive nature of pleural EHE and lack of standardised treatments, emphasising the need for early recognition.

Objectives: Repair of common arterial trunk (CAT) involves establishing the right ventricular outflow tract (RVOT) using either a conduit or a direct right ventricle-pulmonary artery (RVPA) anastomosis (DA). Conduits offer a valved pathway but are limited by durability and availability. The comparative outcomes of these two techniques remain uncertain. This work assessed whether DA improves survival, reduces complications and reinterventions outcomes compared to conduit repair.

Methods: PubMed, Web of Science, EMBASE, and Cochrane Central were searched for studies comparing conduit versus DA for RVOT reconstruction from 20 February 2025 to 30 March 2025. Primary outcome was early mortality; secondary outcomes included haemodynamics, recovery, and complications. Time-to-event data were reconstructed from Kaplan-Meier curves. Pooled hazard ratios (HR), risk ratios (RR), or mean differences (MD) with 95% confidence intervals were calculated using random-effects models.

Results: Eleven studies (767 patients; 419 conduit, 348 DA) were included. Early mortality (RR = 0.61, 95% CI 0.26-1.44, p = 0.220) and long-term survival (HR = 1.11, 95% CI 0.61-2.02, p = 0.738) were similar. Reoperation was more frequent in the conduit group (HR = 1.77, 95% CI 1.05-3.01, p = 0.034). Conduit repair required longer ventilation (MD = 3.44 days, p = 0.010) and hospitalisation (MD = 4.77 days, p = 0.030), with comparable ICU stay and RVOT growth. Truncal valve insufficiency (RR = 0.13, p = 0.130 for Truncal valve vs Conduit) was similar in incidence following DA.

Conclusions: Conduit and DA repairs yield similar survival and postoperative complications in CAT, while DA offers fewer reoperations and faster recovery. Data from future prospective multicentre trials will support decision-making.

A neonate who underwent corrective surgery for cardiac-type total anomalous pulmonary venous connection (TAPVC) was suspected of having a pseudoaneurysm of the left ventricular (LV) free wall on transthoracic echocardiography (TTE) on postoperative day 11. Emergency surgery was performed the following day, revealing LV rupture due to a congenital partial defect of the LV free wall. The defect was successfully repaired using double patches closure reinforced with BioGlue. The postoperative course was uneventful. This case highlights that left ventricular rupture may occur due to an unrecognized congenital defect after neonatal cardiac surgery, particularly in conditions such as TAPVC where the left ventricle is underfilled preoperatively.

The patient was diagnosed with unguarded tricuspid orifice (UGTO), functional pulmonary atresia, and left pulmonary artery hypoplasia. In view of the severe right ventricular dysfunction, the staged single ventricular palliation procedure was selected. The surgical procedure on Starnes operation and left pulmonary artery augmentation, was performed one month after birth. As left pulmonary artery stenosis was diagnosed, secondly, the bidirectional cavopulmonary shunt with additional systemic to pulmonary shunt and intrapulmonary patch septation and left pulmonary artery augmentation with in-situ pericardium were performed. Despite the necessity for additional balloon dilation and surgical blunt dilation, the total cavopulmonary connection operation was ultimately performed, resulting in the successful implementation of staged single-ventricle palliation in conjunction with left pulmonary artery rehabilitation.

Objectives: Selective pulmonary artery perfusion with blood flow occlusion (SPAP-BFO), an experimental endovascular technique, has shown potential to enhance pulmonary drug delivery to the lung. Therefore, it becomes a potential minimally invasive technique for lung cancer and pulmonary metastases. Prior studies predominantly used animal models which do not adequately replicate human vascular anatomy, leaving the clinical feasibility of SPAP-BFO underexplored. To address this gap, we developed a patient-specific 3 D model of the human venous system to evaluate the technical feasibility of SPAP-BFO.

Methods: A 1:1 scale 3 D model of the human venous system was developed and printed based on computed tomography scans of a patient. This model was connected to a perfusion system to simulate blood flow, enabling testing of the catheterization procedure under realistic clinical conditions. Two commercially available balloon catheters, Coda (Cook) and Reliant (Medtronic), were selected based on length and balloon diameter, and their feasibility of reaching and occluding the left and right pulmonary arteries were assessed.

Results: The model effectively simulated human anatomy and blood flow, allowing for both visual and fluoroscopic assessment of the procedure. Both Coda and Reliant catheters successfully reached the target location, when introduced via the femoral vein, and occluded the left and right pulmonary arteries without physically blocking contralateral flow or extending beyond the first bifurcation.

Conclusions: This patient-specific 3 D model provided a valuable platform to evaluate the clinical feasibility of SPAP-BFO. The Coda and Reliant balloon catheters demonstrated effective occlusion of the pulmonary arteries, supporting their potential use in SPAP-BFO procedures.

Objectives: Acute type A aortic dissection (ATAAD) knows high mortality, with emergency surgery being the cornerstone of treatment. The GERAADA-score is advocated in guidelines to predict 30-day ATAAD surgical mortality. This study investigates its performance in a Dutch cohort, with an emphasis on malperfusion definitions, age groups and sex.

Methods: Adults with ATAAD undergoing emergency surgery at five Dutch centres (2007-2024) were included in a multicentre database. External validation of the GERAADA-score was performed with this data, using discrimination (area under the curve(AUC)) and calibration (Brier score, Hosmer-Lemeshow test, and calibration plots). A logistic regression with GERAADA variables was fitted on the study populations and assumptions were checked. Subgroup analyses were conducted based on sex, age in deciles and malperfusion definitions (including imaging and clinical definitions).

Results: 1,146 patients underwent surgery for ATAAD. Observed early mortality was 16.9%(n = 194). Of 1,130 patients included in the external validation cohort, 92.2% had low-intermediate risk (GERAADA-score ≤ 30%). The GERAADA-score showed moderate discrimination (AUC 0.649(95% CI : 0.604-0.694)), with higher AUC for younger patients (50-59 years). The malperfusion definition including ischaemia confirmed by imaging showed the best discriminative power. Calibration was good (Hosmer-Lemeshow, p = 0.754). Logistic regression identified age, catecholamine use, ventilation support, and coronary and peripheral malperfusion as independent risk factors for 30-day mortality, with signs of multicollinearity between preoperative catecholamine use and resuscitation.

Conclusions: In the Dutch-setting the GERAADA-score demonstrated moderate discriminative power and good calibration across relevant subgroups. Adaptations of the GERAADA-score, including conducting a haemodynamic instability variable, may be considered to avoid redundant predictions and boost reproducibility.

Objectives: This study compared long-term outcomes of surgical management for Ebstein's anomaly before and after the introduction of an individualized surgical approach at our centre, including Cone repair.

Methods: We conducted a retrospective, single-centre analysis of patients who underwent surgery for Ebstein's anomaly between 1988 and 2022. Since 2012, early intervention to preserve right ventricular (RV) function before severe deterioration was prioritized. Survival was characterized using Kaplan-Meier estimates, and restricted mean survival time (RMST) was computed up to a specified time horizon. Covariate-adjusted hazard ratios (HRs) were modelled using Cox proportional hazards regression with LASSO-based variable selection.

Results: Out of 162 patients screened, 141 (median age: 14 years; IQR: 5-33 years) were included; 74 underwent surgery before 2012 and 67 after. Patients operated after 2012 were younger (median 7, IQR 1-14 vs 22, IQR 14-44 years; P < 0.001) and more frequently received Cone repair, either alone or combined with a bidirectional Glenn procedure (BDG). Five-year survival improved progressively over the analysed periods: from 81.7% (95% CI: 63.7%-91.3%) before January 2000, to 90% (95% CI: 75.4%-96.1%) between January 2000 and August 2012, reaching 98.5% (95% CI: 89.9%-99.8%) after August 2012. The survival difference before and after 2012 was significant (RMST-based log-rank test: P = 0.0094). Cox regression identified Carpentier classification above type B (HR: 6.19; 95% CI: 1.69-22.68; P = 0.006) and postoperative sepsis within 30 days (HR: 7.75; 95% CI: 2.09-28.75; P = 0.002) as risk factors for increased mortality. Cone repair itself was not associated with increased mortality (HR: 1.01; 95% CI: 0.11-9.57; P = 0.991), whereas BDG was associated with a lower hazard (HR: 0.11; 95% CI: 0.01-0.92; P = 0.041).

Conclusions: An individualized strategy that favoured earlier intervention, including Cone repair with or without BDG, was associated with improved survival. These findings highlight the importance of tailoring surgical strategies to anatomical and haemodynamic status in Ebstein's anomaly.

Objectives: Prolonged cardiopulmonary bypass (CPB) time during coronary artery bypass grafting (CABG) is associated with poor outcomes, however, the association of other operating room (OR) times is less understood. We studied the impact of OR times on outcomes and resource utilization after CABG.

Methods: Patients undergoing isolated primary CABG from a large multicentre regional collaborative were analysed. The impact of risk-adjusted total OR, surgery, non-surgery, CPB, and off-CPB times on morbidity, extubation time, ICU and hospital length of stay (LOS), cost, and mortality, was studied. Multivariable regressions were performed adjusting for STS predicted risk of morbidity or mortality, intraoperative blood transfusion, CPB time, cross-clamp time, presence of a cardiothoracic surgery fellowship program, and year of surgery. Our adjustment accounted for patient and intraoperative factors that contribute to complexity and intraoperative course of surgery. All models incorporated centre as a random effect to account for hospital-level variations.

Results: Among 29 206 patients (mean age 64.8 years, 76% male), median OR, surgery, non-surgery, and CPB times were 308, 235, 72, and 141 minutes, respectively. Longer surgery times were significantly associated with complications, prolonged ventilation, longer ICU and hospital LOS, and mortality. Similarly, increasing non-surgery OR time was significantly associated with worse outcomes, including longer LOS and complications. Each additional 15 minutes in the OR was associated with increased odds of complications, mortality, and cost.

Conclusions: Longer non-surgical OR times are associated with adverse outcomes and increased cost. Improving OR efficiency may contribute to better patient outcomes.

Objectives: Elevated red cell distribution width (RDW) has been associated with adverse outcomes in coronary artery disease but its role in bleeding after cardiac surgery is unclear. We evaluated whether preoperative RDW predicts bleeding after isolated coronary artery bypass grafting (CABG).

Methods: This was a nationwide retrospective study of patients undergoing isolated CABG in Iceland, 2003-2019. RDW was analysed continuously (per 1% increase) and dichotomized (>14.0% vs ≤14.0%). Primary bleeding outcomes included transfusion >4 red blood cell units, re-exploration for bleeding, and chest tube output >1000 mL/24h. Multivariable logistic regression adjusted for demographics, comorbidities, operative urgency, cardiopulmonary bypass, and perioperative factors.

Results: The study included 1929 patients. Elevated RDW was associated with older age, anaemia, comorbidities, and urgent procedures. After adjustment, higher RDW predicted transfusion >4 RBC units (OR 1.25 per 1%, OR 1.72 for >14.0%), re-exploration (OR 1.30 per 1%, OR 2.39 for >14.0%), and chest tube output >1000 mL/24 h (OR 1.13 per 1%, OR 1.34 for >14.0%). RDW was also associated with greater platelet/plasma use, longer ICU stay, and major complications, but not to 30-day mortality (OR 1.21, 95% CI 0.55-2.52).

Conclusions: Elevated RDW was independently associated with multiple bleeding complications after CABG. RDW may serve as a simple, inexpensive biomarker to improve preoperative bleeding risk stratification in CABG patients.