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.

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: 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.

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: 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.