Interdisciplinary cardiovascular and thoracic surgery最新文献

Objectives: Robotic-assisted thoracic surgery (RATS) has transitioned from an emerging adjunct to an established component of minimally invasive thoracic practice. Advances in multi-platform systems, single-port (SP) technology, and artificial intelligence (AI)-driven analytics are shaping the next phase of surgical precision, ergonomics, and patient-specific approaches.

Methods: We synthesized evidence from randomized controlled trials (RCTs), observational series, national training initiatives, and recent technological innovations to assess the current status, potential benefits, limitations, and future trajectory of RATS. Data sources included RVlob, ROMAN, and RAVAL-4 RCTs; the SORTS UK national training survey; our own thymic resection comparative series; and SP platform feasibility studies.

Results: RCT data demonstrate oncological equivalence between RATS and video-assisted thoracoscopic surgery (VATS), with some evidence for improved lymph node yield. National survey findings underscore the need for structured training pathways to meet evolving technical demands. Early SP platform experiences indicate feasibility and safety in high-volume centres, but widespread adoption is constrained by limited availability, instrumentation, and independent validation. AI-enhanced surgical planning and intraoperative navigation are promising adjuncts, though their clinical impact remains to be defined. Cost, access inequities, and reproducibility outside expert centres continue to pose challenges.

Conclusions: The trajectory of RATS is towards the integration of precision oncology, less invasive access strategies, and data-driven surgical intelligence. Realizing this vision will require rigorous comparative studies, equitable access, and incorporation into structured training to ensure safe, reproducible, and patient-centred adoption worldwide.

Background: Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) in small surgical bioprostheses presents unique challenges due to high residual gradients and risk of coronary obstruction.

Case summary: We report a case of an 86-year-old man with a degenerated Mitroflow 19 mm valve who underwent ViV TAVI via transcarotid access using a 20 mm Myval valve. Significant underexpansion was observed post-implantation, with elevated transvalvular gradients. Bioprosthetic valve fracture (BVF) was performed using an 18 mm non-compliant balloon, resulting in full valve expansion and gradient reduction. Shortly after BVF, the patient developed myocardial stunning and hemodynamic collapse, requiring urgent veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Extracorporeal membrane oxygenation was successfully weaned after 48 hours, and the patient was discharged in stable condition.

Conclusion: This is the first reported case of transcarotid ViV TAVI with BVF in a 19 mm Mitroflow bioprosthesis, successfully rescued with ECMO. The report highlights the importance of appropriate access planning, valve selection, and ECMO standby in complex high-risk anatomies.

Objectives: The recent increase in sublobar resections has been driven by favourable long-term outcomes and advances in stapling devices. However, maintaining an adequate resection margin remains a critical oncological requirement. This study aimed to investigate whether deep wedge resection induces subpleural alveolar injury that could lead to margin overestimation by creating undetectable internal cavities.

Methods: We retrospectively analysed 33 consecutive patients who underwent wedge resection and CT imaging of resected lung specimens between December 2018 and February 2025. CT was performed on inflated specimens to better visualize internal lung architecture. We assessed the presence of an "empty space" adjacent to the staple line and correlated it with clinical factors, including depth of wedge resection (WR). Additionally, ex vivo porcine lung models were used to simulate deep WR, analyse compression effects, and identify histological damage caused by stapler compression.

Results: CT imaging revealed empty spaces adjacent to the staple line in 10 of 33 specimens (30.3%), with a mean cavity length of 8.25 ± 3.2 mm. This artifact was significantly associated with deeper WR (≥26.3 mm) and increased stapler cartridge usage (median: 4 vs 3, P = .0298). In porcine experiments, compression to 2 mm thickness resulted in internal parenchymal rupture without pleural tearing, replicating the clinical findings.

Conclusions: This study identified a potential mechanism by which deep wedge resection may lead to overestimation of the pathological margin due to stapler-induced parenchymal rupture. Further large-scale studies integrating oncological outcomes are warranted to clarify how wedge resection and segmentectomy should be appropriately selected for deep peripheral lung lesions.

Objectives: For the treatment of aortic valve stenoses, both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) are available. We compared the frequently used Euroscore with the AKL-Cath- and the AKL-Chir Score, describing the mortality risk of the 2 different treatment methods.

Methods: Based on a retrospective cohort study using mandatory quality assurance data, we analysed the frequency and the outcomes (primary end-point: in-hospital mortality) of all patients treated in Germany between 2015 and 2020. The observed results were compared to the predicted risk using the Euroscore, the AKL-Cath Score, and the AKL-Chir Score.

Results: Our data show a reduction in the number of isolated SAVR procedures from 9790 in 2015 to 6106 in 2020, corresponding to a 37.6% decrease. Over the same period, the number of TAVI procedures increased from 15 653 to 21 501, an increase of 37.3%. Regarding in-hospital mortality following TAVI, there was a decline from 4% (2015) to 2.5% (2020), while in-hospital mortality following SAVR remained nearly constant at 3%. Over the study period, there is an overestimation of TAVI risk while simultaneously underestimating SAVR risk by EuroSCORE II. In contrast, the mortality risk of patients is well estimated using the AKL-Kath Score in the TAVI group and the AKL-Chir Score in the SAVR group. The AKL-Chir Score in TAVI patients overestimates their mortality, while the AKL-Kath Score underestimates the mortality of SAVR patients.

Conclusions: AKL-Chir score and AKL-Cath score estimate the mortality risk of SAVR and TAVI patients more precisely than the Euroscore II.

Objectives: Pure anterior mediastinal cysts (pAMC) are uncommon and typically benign lesions. In contrast to solid anterior mediastinal tumours, there are no standardized diagnostic or management guidelines, despite a small but clinically significant risk of malignancy. The goal of this study was to identify preoperative factors associated with malignancy in order to develop a clinical algorithm to guide the diagnosis and management of pAMC.

Methods: This retrospective single-centre study was conducted at Toulouse University Hospital and included patients diagnosed with pAMC between January 2012 and June 2025. Logistic regression was used to identify preoperative predictors of thymoma or germ cell tumours.

Results: A total of 70 patients were diagnosed with pAMC, 26 of whom underwent surgical resection. On multivariate analysis, hypermetabolism on positron emission tomography-computed tomography (PET-CT) was significantly associated with a final pathological diagnosis of thymoma or germ cell tumour (odds ratio, 43.21 [2.81-663.93], P = .007). Lesion size greater than 4 cm was also associated with malignancy on univariate analysis (odds ratio: 10.50 [1.50-73.67], P = .02), though this did not remain significant in multivariate analysis. Based on these findings, we proposed a decision-making algorithm incorporating PET-CT as a first-line investigation.

Conclusions: Hypermetabolism on PET-CT is a strong preoperative predictor of malignancy in lesions presenting as pAMC. Prospective multicentre studies are warranted to validate additional prognostic markers and optimize imaging strategies for the management of pAMC.

Objectives: Prolonged air leaks are common after thoracic surgery and may be managed with synthetic aerostatic devices. This study assessed the impact of the Neoveil patch on air leak duration, hospital stay, and postoperative pneumonia.

Methods: We conducted a retrospective monocentric study at Amiens University Hospital including adults undergoing lung resection between 2014 and 2024. Patients were divided into three groups: those receiving Neoveil, those not receiving it because of absence of indication, and those operated before its introduction in 2017. For analysis, the two latter groups were pooled as the Non-Neoveil arm. To address confounding, a propensity score was built from baseline covariates with standardized mean difference >5%, and inverse probability weighting was applied. The primary end-point was air leak duration, assessed with weighted linear regression. Secondary outcomes were hospital stay and postoperative pneumonia, analyzed with weighted linear and logistic regression.

Results: Among 1216 patients, 313 (26%) received Neoveil. Compared with the control group, Neoveil use was associated with shorter air leak duration both before adjustment (-1.01 days; P = .0004) and after adjustment (-0.67 days; P = .0042). Hospital stay was also reduced (-1.88 days before adjustment; -1.09 days after adjustment; P = .0022). No significant difference was observed for postoperative pneumonia after adjustment (adjusted Odds Ratio 0.73, 95% Confidence Interval 0.48-1.11; P = .14).

Conclusions: Neoveil use was associated with reduced air leak duration and shorter hospital stay following lung resection, without significant impact on pneumonia. These findings support its potential role in enhancing postoperative recovery and highlight the need for confirmation in prospective multicentre studies.

Objectives: Robot-assisted mitral valve replacement has been shown to be comparable to conventional surgery in terms of safety and efficacy. Our institution has performed robot-assisted mitral valve replacement using the Da Vinci Surgical System for over a decade. This study aimed to evaluate the time-related evolution of clinical outcomes and the impact of the surgical learning curve.

Methods: Patients who underwent robot-assisted mitral valve replacement between July 2013 and January 2024 were evaluated. All procedures were performed by 4 surgeons certified in robotic cardiac surgery, each with prior experience of more than 100 conventional mitral valve replacements. To assess the learning curve, cumulative sum analysis was conducted on cardiopulmonary bypass time and the Mitral Surgery Complexity Score.

Results: A total of 233 patients were included in the analysis. The mean patient age was 48.4 (13.9) years; 117 (50.2%) were male. The mean cardiopulmonary bypass time was 170.3 (55.1) min. Cumulative sum analysis of cardiopulmonary bypass time revealed 3 phases: a learning phase (cases 1-27), a proficiency phase (cases 28-92), and a mastery phase (cases 93 onward). Mitral Surgery Complexity Scores decreased during the early phase, followed by an increase after case 92, indicating a transition towards more complex cases.

Conclusions: Robot-assisted mitral valve replacement has a measurable learning curve, with surgical efficiency and case complexity evolving over time. Approximately 93 procedures appear necessary to achieve operative stability and to confidently expand indications to include more complex patients.

Objectives: This study investigates differences in short- and mid-term outcomes in patients without malperfusion undergoing surgery for acute type A aortic dissection between specialized aortic surgeons and non-aortic surgeons.

Methods: Patients who underwent surgery for acute type A aortic dissection between 2013 and 2023 defined as M0 (no malperfusion) according to the type-entry-malperfusion classification were included and divided into 2 groups according to the surgeon's expertise: aortic surgeon vs non-aortic surgeon group, whereas an aortic surgeon was defined by expertise in extensive aortic arch surgery including frozen elephant trunk implantation on a regular basis (average ≥5/year). After propensity score matching, the groups were compared in terms of intraoperative variables and outcomes including a primary combined end-point consisting of 30-day mortality and/or CT-confirmed stroke.

Results: The matched cohort comprised 2 balanced groups with 234 patients (117 in each group). Cardiopulmonary bypass, cross-clamp and distal arrest times did not differ significantly between the groups. However, more extensive aortic surgery was performed by aortic surgeons: aortic root replacement (Bentall) (P = .007; odds ratio [OR] 1.18 [CI, 1.05-1.32]), valve-sparing root replacement (David) (P = .013; OR 1.05 [CI, 1.01-1.10]), and frozen elephant trunk implantation (P < .001; OR 1.18 (CI, 1.09-1.27]). The combined end-point of 30-day mortality and/or CT-confirmed stroke was 26% in the non-aortic surgeon vs 23% in the aortic surgeon group (P = .54; OR 0.97 [CI, 0.86-1.08]). Further clinical outcomes, including 5-year survival, did not differ significantly (P = .170).

Conclusions: Patients without preoperative malperfusion undergoing surgery for ATAAD show no differences in terms of short- and mid-term outcomes between specialized aortic and non-aortic surgeons. However, more extensive aortic repair may be performed safely by specialized aortic surgeons. These results support the definition of an aortic surgeon based on experience with the frozen elephant trunk technique and may advocate for call coverage by an aortic surgeon for type A repair at high-volume centres.

A nuclear protein in testis (NUT) carcinoma is a rare, aggressive malignancy often diagnosed late due to non-specific symptoms and low awareness. A 69-year-old woman presented with haemoptysis and a positron emission tomography-avid lung nodule (cT1N0M0). An initial bronchoscopic biopsy suggested small cell carcinoma with negative NUT staining. Following a lobectomy, immunohistochemical analysis showed strong nuclear NUT positivity, and fluorescence in situ hybridization confirmed NUT rearrangement. This case was atypical due to the patient's age, early stage, and initial misdiagnosis from a limited biopsy. The non-specific presentation of an NUT carcinoma requires a high degree of suspicion, and small biopsies risk a misdiagnosis.

Objectives: We sought to evaluate compliance and flow of the ascending aorta of patients with decellularized aortic homografts compared to donor age-matched healthy controls.

Methods: Male patients and donor age-matched male healthy controls were included. Cardiac function was evaluated by retrospectively electrocardiography-gated cine balanced steady-state free precession magnetic resonance imaging (MRI). Time-resolved 2- and 3-dimensional phase-contrast sequences were used to determine relative area change and pulse wave velocity as surrogate parameters for vessel compliance as well as maximum blood flow velocity.

Results: Thirteen patients were matched according to the age of their homograft donor (median 42 years, interquartile range [IQR] 32-50) to 7 healthy controls (median 40 years, IQR 36-48). Time to post-operative MRI was 3.33 (1.33-4.50) years. Relative area change in the proximal ascending aorta was significantly lower in the homograft group compared to healthy controls (26%, IQR 23-44 vs 38%, IQR 24-44, P < .001), with no significant difference observed in the distal ascending aorta (22%, IQR 22-33 vs 34%, IQR 22-41, P = .438). Maximum blood flow velocity in the proximal ascending aorta was significantly higher in the homograft group compared to healthy controls (168 cm s-1, IQR 148-188 vs 115 cm s-1, IQR 114-120, P = .009).

Conclusions: Decellularized aortic homograft patients seem to have a reduced compliance of the proximal ascending aorta compared to donor age-matched healthy controls. This may be attributable to the in vitro decellularization process or post-operative graft degeneration. These findings highlight the ultimate need for follow-up data to understand the long-term in vivo effects of decellularized human tissue. This study is a follow-up study of the patients included in the ARISE Study registered on ClinicalTrials.gov (NCT02527629). For the purposes of this manuscript, healthy individuals were subsequently recruited to serve as the control group.