Interdisciplinary cardiovascular and thoracic surgery最新文献

Objectives: As transcatheter aortic valve replacement (TAVR) expands to lower-risk populations, understanding contemporary patterns of complications requiring surgical intervention remains critical. This study examines the incidence, predictors, and outcomes of major TAVR complications.

Methods: The National Inpatient Sample (2016-2021) was queried to identify adult patients undergoing TAVR. Major complications were defined as surgical aortic valve replacement, coronary artery bypass grafting, aortic intervention, pericardial drainage, VA-ECMO, cardiac repair, or diagnosis of aortic dissection/rupture. Multivariable logistic regression identified predictors of complications and failure-to-rescue.

Results: Among 383 395 TAVRs, 4685 (1.2%) experienced major complications. Overall in-hospital mortality was 1.3%. Mortality was 26.0% in patients with major complications versus 1.0% without (P < .001). Stroke rates were also higher in patients with major complications (7.5% versus 1.8%, P < .001). Complications were associated with longer length of stay (8 vs 2 days) and higher hospital costs ($79,302 vs $45,469). Independent predictors of complications included age <65 (OR 2.27), bicuspid aortic valve (OR 1.79), thoracic aortic aneurysm (OR 1.49) and female sex (OR 1.24), while elective admission was protective (OR 0.51). Among patients with complications, VA-ECMO cannulation (OR 10.36), cardiac chamber repair (OR 3.14), and aortic dissection/rupture (OR 1.68) were strongest predictors of mortality.

Conclusions: While the proportion of TAVR patients experiencing surgical emergencies has remained stable over time, the overall prevalence is increasing with the growth of TAVR, and these complications are associated with an in-hospital mortality rate of greater than 25%. Younger age, female sex, bicuspid valve, and thoracic aneurysm are associated with increased risk of major complications.

Objectives: This quality improvement project aimed to enhance operating room efficiency in a newly established paediatric cardiac operating room by focusing on key performance indicators (KPI), including (1) first case on-time start (FCOTS), (2) turnover time (TOT), and (3) case cancellation rate through targeted interventions.

Methods: This initiative was conducted at the Division of Cardiothoracic Sciences, Sindh Institute of Urology and Transplantation (SIUT), from July 2023 to June 2024, using a stepwise Plan-Do-Study-Act (PDSA) methodology for each KPI, including baseline data, interventions, and outcome analysis. Root Cause Analysis with Fishbone and 5 Whys identified gaps, guiding targeted improvements. Weekly performance was tracked on a spreadsheet, and messaging updates were provided, while control charts and feedback sessions ensured progress. Leadership maintained accountability. Pre- and post-intervention results were compared using control charts for FCOTS, case cancellation rate, and for TOT.

Results: Following implementation of targeted QI interventions, FCOTS compliance improved from 50% to 91%, mean TOT decreased from 34 to 27 minutes, and case cancellation rate dropped from 30% to 7%.

Conclusions: Significant improvements in operating room efficiency can be achieved through practical, scalable quality improvement methods using available resources. Our findings support the implementation of KPI-driven QI models in similar resource-limited paediatric surgical settings.

Oesophageal leakage is a serious complication that can lead to infection, sepsis, malnutrition, and death. Negative Pressure Wound Therapy has been increasingly used to treat oesophageal leaks; however, in cases of cervical oesophageal leakage, deep tract and anatomical complexity often hinder an airtight seal and limit transmission of negative pressure. We developed a modified Negative Pressure Wound Therapy technique by connecting a surgical drain to the base of the foam dressing and securing it with subcutaneous occlusive sutures to ensure a reliable seal and effective negative pressure transmission. Four cases of modified application were included in this study. All leaks were controlled without complications attributable to the procedure. The modified Negative Pressure Wound Therapy technique effectively addresses the limitations of conventional methods in complex anatomical regions. By ensuring a reliable occlusive seal and enhancing negative pressure transmission, this approach promotes optimal wound healing through improved exudate clearance and reduced maceration.

Objectives: Patients with aortic stenosis (AS) undergoing haemodialysis (HD) often experience more rapid disease progression and poorer prognosis than non-dialysis patients; however, the underlying mechanisms remain unclear. This study aimed to elucidate clinical and molecular differences between HD and non-HD patients with AS, focusing on transcriptomic profiling of resected aortic valves.

Methods: We retrospectively analysed 183 patients with severe AS who underwent surgical aortic valve replacement at the University of Yamanashi Hospital from February 2015 to May 2024. Among them, 34 patients were receiving maintenance HD, while 149 were not. Clinical data, echocardiographic findings, and CT-based valve calcification were assessed. RNA sequencing was conducted on aortic valve specimens from 5 HD and 4 non-HD patients. Differentially expressed genes were identified, followed by enrichment analysis and immune cell profiling using CIBERSORTx.

Results: Haemodialysis patients exhibited lower body mass index, a higher prevalence of ischaemic heart disease, elevated C-reactive protein and B-type natriuretic peptide levels, and impaired diastolic function compared to non-HD patients. RNA sequencing revealed 35 upregulated and 30 downregulated genes in HD valves. Enrichment analysis demonstrated that genes involved in immune response and ossification were upregulated in aortic valves from HD patients. CIBERSORTx analysis suggested increased macrophage infiltration. Comparison with public datasets identified HD- associated gene signatures.

Conclusions: Patients with AS on HD exhibited distinct clinical features and gene expression profiles. Upregulation of immune and ossification-related genes, alongside macrophage infiltration, suggests a key role for immune response in AS progression among HD patients.

Objectives: Transcatheter treatment for valvular heart diseases has markedly expanded its indications due to reduced invasiveness and hospitalization time. Despite favourable results, several peculiar and more frequent shortcomings than occur with a surgical-based implant have been reported. This review provides the currently available information regarding a transcatheter heart valve (THV) implant and reoperation, focusing on recent available data about surgical management strategies for THV degeneration.

Methods: For this narrative review, we searched Medline through the end of March 2025 using medical subject headings and text words supplemented by scanning the bibliographies of recovered articles. The terms "transcatheter valve degeneration," "TAVI degeneration," "surgical treatment," and "surgical explant" have been combined using the Boolean operator "AND".

Results: Currently available articles focus specifically on the aortic THV explant. Peculiar intraoperative (like coronary ostium, aortic wall and annular injury due to THV explant) or short-term postoperative complications related to THV explant have been reported. Thirty-day mortality has been shown to range between 12% and 32.6%, and only short and heterogeneous follow-up periods are available to date. A careful work-up to indicate that the valve-in-valve procedure is not feasible or not appropriate when facing degenerated THV and a cautious, detailed plan of the surgical explant have been recently recommended.

Conclusions: THV explants due to valve degeneration are rapidly increasing, but, due to the related risk for intra- and post-procedural complications, careful preoperative evaluation and intraoperative handling are warranted.

Gastroesophageal intussusception is a rare but clinically significant condition necessitating prompt diagnosis and management. This highlights the importance of early recognition and intervention to prevent severe complications such as oesophageal perforation. Endoscopic assessment and surgical intervention remain the cornerstone of the management, tailored to the clinical severity and surgeon's expertise. The prognosis largely depends on the timeliness of diagnosis and intervention, with early treatment typically resulting in favourable outcomes.

Objectives: T4 non-small-cell lung cancer comprises a biologically and anatomically heterogeneous group. The 9th edition of the Tumour-Node-Metastasis staging system introduced refined T4 definitions and subdivided N2 disease into single- and multi-station involvement. This study aimed to assess long-term survival and prognostic factors in surgically treated T4 non-small-cell lung cancer patients, focusing on T4 subgroups and nodal status.

Methods: We retrospectively analysed patients who underwent resection for pathologically confirmed T4 non-small cell lung cancer between 2006 and 2024. Patients were categorized based on T4 criteria: tumour diameter >7 cm, adjacent structure invasion, or multiple T4 features. Survival outcomes were assessed using Kaplan-Meier, Aalen-Johansen and Cox regression analyses.

Results: A total of 191 patients were analysed. The 5-year overall survival rate was 34.1%, varying across subgroups: 38.7% (size), 29.9% (invasion), and 6.1% (multiple criteria) (P < .001). Adjuvant chemotherapy was associated with improved overall survival (hazard ratio [HR]: 0.511; P = .001), while N2 disease (HR: 1.750; P = .012) and multiple T4 features (HR: 2.590; P < .001) predicted worse outcomes. Similar patterns were observed in recurrence-free survival. N2 involvement was particularly adverse in the invasion group.

Conclusions: T4 aetiology and nodal status significantly impact survival following surgery. These findings support the prognostic utility of the 9th Tumour-Node-Metastasis edition and underscore the value of tailored surgical strategies.

Objectives: Anatomical segmentectomy is increasingly used for early-stage lung cancer due to its parenchymal-sparing benefits. However, it remains technically challenging, and procedural complexity is often inconsistently defined. Robotic-assisted surgery, offering enhanced dexterity and visualization, has become more widespread but still requires high technical expertise. This study aimed to identify preoperative factors associated with procedural complexity and evaluate its impact on postoperative outcomes.

Methods: This single-centre cohort study included 160 consecutive patients who underwent robotic segmentectomy by 2 expert surgeons between November 2018 and August 2025. Complex procedures were defined as those with operative time >125 min (75th percentile), conversion to another surgical approach, or changes in the planned resection due to intraoperative technical challenges. Logistic regression was used to identify preoperative variables associated with complexity. Postoperative outcomes were compared between complex and non-complex cases.

Results: Thirty-seven segmentectomies (23.1%) were classified as complex. Predictors of complexity included age (odds ratio [OR] = 1.042, P = .063), transverse pleural diameter (OR = 0.716, P = .089), and number of staple planes (OR = 1.644, P = .058), while the presence of emphysema (OR = 0.428, P = .076) appeared to be protective. Mortality, overall morbidity, prolonged air leak, and readmission rates were similar between groups. However, complex cases had significantly higher rates of major morbidity (13.5% vs 1.6%, P = .008), reintervention (10.8% vs 0.8%, P = .010), and longer hospital stays (median 3 vs 2 days, P = .004).

Conclusions: This exploratory analysis identified preoperative factors associated with procedural complexity in robotic segmentectomy. These findings may help improve patient selection, surgical planning, resource allocation, and structured training.

We present the case of a 72-year-old man with symptomatic severe aortic regurgitation and moderate aortic stenosis, and an annular diameter of 30 mm, exceeding the recommended range for sutureless Perceval valve implantation. To reduce the annular size to allow implantation of the Perceval XL valve, an annular plication technique was employed, involving three horizontal mattress sutures placed at the interleaflet triangles. A totally endoscopic approach via right mini-thoracotomy was utilized. Postoperative echocardiography confirmed excellent valve positioning and no paravalvular leak. The patient recovered uneventfully and remained asymptomatic with good prosthesis function at the 3-year follow-up. This case demonstrated that annular plication enables the safe use of the Perceval valve in patients with a mildly oversized annulus and may expand its applicability in minimally invasive settings.