JTCVS open最新文献_第10页

Simulation-guided design of leaflet height in bicuspidization of the aortic valve 主动脉瓣二尖瓣成形术中小叶高度的模拟引导设计

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.09.038

Alexander D. Kaiser PhD , Perry S. Choi MD , Amit Sharir BS , Alison L. Marsden PhD , Michael R. Ma MD

Background

Bicuspidization repair is typically applied to severe congenital aortic valve lesions. Increasingly, this repair is recognized as an effective and durable surgical approach. The consequences of postoperative leaflet geometry in this repair are relatively unstudied, especially compared with current understanding of optimal geometry for a trileaflet valve. In this work, a computational approach was systematically applied to study the effect of changes in leaflet geometric height in symmetric bicuspidization repair.

Methods

Eight model valves with 4 geometric heights spanning a range of typically observed values were constructed at 2 free-edge lengths. Heights varied when loaded in diastole from approximately one-half the annular diameter to just below the annular diameter. Fluid–structure interaction simulations were performed to study the coupled dynamics of the valve and blood. Models were evaluated for stenosis, regurgitation, hemodynamics, mechanics, and diastolic gross morphology.

Results

Cases with loaded geometric height 0.64 to 0.79 times the annular diameter showed the overall best performance, with a coaptation reserve of 4 to 7 mm. Cases with geometric height approximately one-half the annular diameter showed severe regurgitation. Cases with geometric height 0.86 to 0.95 times the annular diameter showed less “crisp” coaptation alignment and the appearance of excessive leaflet material.

Conclusions

The intermediate range of geometric height appeared best, with insufficient height causing regurgitation. More geometric height was not always clearly better, as excessively tall leaflets showed less alignment in the coaptation regions.

背景：双尖瓣修复术通常应用于严重的先天性主动脉瓣病变。越来越多地，这种修复被认为是有效和持久的手术方法。术后小叶几何形状在这种修复中的影响相对未被研究，特别是与目前对三叶瓣膜最佳几何形状的理解相比。在这项工作中，系统地应用计算方法研究了对称双尖化修复中小叶几何高度变化的影响。方法在2种自由边缘长度上构建8个具有4种几何高度的典型观测值范围的模型阀。当在舒张期加载时，高度从大约环径的一半到略低于环径。通过流固耦合仿真研究瓣膜与血液的耦合动力学。评估模型的狭窄、反流、血流动力学、力学和舒张大体形态。结果负载几何高度为环径0.64 ~ 0.79倍的病例整体表现最佳，适应储备为4 ~ 7 mm。几何高度约为环径一半的病例返流严重。几何高度为环径0.86 ~ 0.95倍的病例，表现出较不“脆”的配合排列，出现过多的小叶物质。结论几何高度中间区间表现最佳，高度不足引起反流。几何高度并不总是越高越好，因为过高的小叶在适应区域显示出较少的排列。

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引用次数: 0

Thoracic endovascular aortic repair for advanced esophageal cancer invading the aorta: A prognosis analysis among 124 patients 124例晚期食管癌侵犯主动脉的胸部血管内主动脉修补术的预后分析

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.09.021

Hsiao-Hung Lu MD , Ke-Cheng Chen MD, PhD , Chih-Yang Chang MD, PhD , Pei-Ming Huang MD, PhD , Mong-Wei Lin MD, PhD , Shuenn-Wen Kuo MD, PhD , I-Hui Wu MD, PhD , Jang-Ming Lee MD, PhD

Objectives

Advanced esophageal cancer invading the aorta is considered an unresectable disease with a poor prognosis. We evaluated the clinical impact of elective thoracic endovascular aortic repair implantation on the prognosis of such patients.

Methods

We retrospectively evaluated patients with advanced esophageal cancer and aortic invasion who underwent thoracic endovascular aortic repair to assess its prognostic impact under multimodal treatment.

Results

Overall, 124 patients were enrolled. Among these, 16 patients underwent salvage thoracic endovascular aortic repair in response to bleeding from an aorto-esophageal fistula, 46 patients received elective thoracic endovascular aortic repair with esophagectomy after diagnosing aortic invasion by a tumor, and 62 patients underwent elective thoracic endovascular aortic repair without esophagectomy after diagnosing aortic invasion by a tumor. The median overall survival time was 3.57, 6.90, and 16.90 months for patients who underwent salvage thoracic endovascular aortic repair, elective thoracic endovascular aortic repair without esophagectomy, and elective thoracic endovascular aortic repair with esophagectomy, respectively (P < .001). Under multivariate analysis, compared with patients who underwent salvage thoracic endovascular aortic repair, those who received elective thoracic endovascular aortic repair with and without esophagectomy had reduced odds ratios of mortality (95% CI) of 0.21 (0.11-0.41) and 0.38 (0.20-0.74), respectively.

Conclusions

Compared with salvage thoracic endovascular aortic repair, elective thoracic endovascular aortic repair implanted after diagnosis for esophageal cancer with aortic invasion is associated with improved overall survival. It provides the opportunity for esophagectomy, further prolonging survival compared with those without esophagectomy.

目的晚期食管癌侵犯主动脉是一种预后较差的不可切除的疾病。我们评估择期胸腔血管内主动脉修复植入术对此类患者预后的临床影响。方法回顾性分析晚期食管癌合并主动脉侵犯行胸腔血管内主动脉修复术的患者，评估多种治疗方式对其预后的影响。结果共纳入124例患者。其中16例因主动脉-食管瘘出血行补救性胸主动脉腔内修复术，46例诊断为肿瘤侵犯后行选择性胸主动脉腔内修复术合并食管切除术，62例诊断为肿瘤侵犯后行选择性胸主动脉腔内修复术不切除食管。救救性胸椎血管内主动脉修复术、择期胸椎血管内主动脉修复术不加食管切除术和择期胸椎血管内主动脉修复术合并食管切除术患者的中位总生存时间分别为3.57、6.90和16.90个月（P < .001）。在多因素分析中，与接受补救性胸腔血管内主动脉修复术的患者相比，接受择期胸腔血管内主动脉修复术合并和不合并食管切除术的患者死亡率优势比（95% CI）分别为0.21（0.11-0.41）和0.38（0.20-0.74）。结论食管癌合并主动脉侵犯诊断后择期植入胸腔血管内主动脉修复术与补救性胸腔血管内主动脉修复术相比可提高总生存率。它为食管切除术提供了机会，与未行食管切除术的患者相比，进一步延长了生存期。

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引用次数: 0

The effect of surgeon experience on the short-term outcomes of aortic annular enlargement 外科医生经验对主动脉环扩大短期疗效的影响

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.09.039

Alexander Makkinejad MD , Barbara C.S. Hamilton MD, MS , Robert B. Hawkins MD, MSc , Shinichi Fukuhara MD , Karen Kim MD , Paul Tang MD, PhD , Himanshu J. Patel MD , Francis Pagani MD , Gorav Ailawadi MD, MBA , Bo Yang MD, PhD

Objective

To determine whether surgeon case volume influences short-term outcomes after aortic annular enlargement (AAE).

Methods

From January 2019 to December 2023, 202 patients underwent isolated first-time aortic valve replacement with aortic annular enlargement by 11 surgeons. Two performed ≥25 AAEs per year (high case volume surgeons), whereas the other 9 performed <25 AAEs per year (low case volume surgeons). The short-term outcomes were compared between the high case volume surgeons (n = 126) and the low case volume surgeons (n = 76).

Results

The groups were similar in age, sex, body surface area, and all measured preoperative comorbidities, including Society of Thoracic Surgeons Predicted Risk of Mortality scores. Preoperative aortic valve mean gradients and aortic valve areas did not significantly differ between the groups. The high case-volume surgeons implanted prostheses that were on average one size larger (size 27 vs size 25). All measured perioperative outcomes including operative mortality were not statistically different between groups. Kaplan-Meier estimation of survival at 4 years was 96.0% among the patients of the high case-volume surgeons and 92.5% among those of the low case-volume surgeons (P = .57). On follow-up echocardiography, patients of the high case-volume surgeons had lower aortic valve mean gradients (7 mm Hg vs 8 mm Hg, P = .005), larger aortic valve areas (2.2 cm² vs 1.9 cm², P = .039), and less patient-prosthesis mismatch (6.9% [5/72] vs 26% [11/43], P = .005).

Conclusions

AAE can be performed safely by surgeons with less experience with the procedure, but surgeons who perform AAE more frequently implant larger valves with better hemodynamics.

目的探讨手术病例量对主动脉环扩大术后短期预后的影响。方法2019年1月至2023年12月，11名外科医生对202例首次主动脉瓣置换术患者行主动脉环扩大术。其中2例每年进行≥25次ae（高病例量外科医生），而其他9例每年进行25次ae（低病例量外科医生）。比较高病例量外科医生（n = 126）和低病例量外科医生（n = 76）的短期预后。结果两组在年龄、性别、体表面积和所有术前合并症（包括胸外科学会预测死亡风险评分）方面相似。术前主动脉瓣平均梯度和主动脉瓣面积组间无显著差异。高病例量的外科医生植入的假体平均大1号（27号对25号）。两组围手术期的所有测量结果包括手术死亡率均无统计学差异。Kaplan-Meier估计的4年生存率在高病例量外科医生中为96.0%，在低病例量外科医生中为92.5% （P = 0.57）。在随访超声心动图中，高病例量外科医生的患者主动脉瓣平均梯度较低（7 mm Hg vs 8 mm Hg, P = 0.005），主动脉瓣面积较大（2.2 cm2 vs 1.9 cm2, P = 0.039），患者与假体不匹配较少（6.9% [5/72]vs 26% [11/43], P = 0.005）。结论经验不足的外科医生可以安全的进行瓣膜置换术，但进行瓣膜置换术次数越多的外科医生植入的瓣膜越大，血流动力学就越好。

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引用次数: 0

Real-world perioperative outcomes of neoadjuvant chemoimmunotherapy in non–small cell lung cancer 非小细胞肺癌新辅助化疗免疫治疗的围手术期疗效

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.09.016

Giorgio Caturegli MD, Michael F. Kaminski MD, Maureen Canavan PhD, Oluwaseun F. Ayoade MD, MSHA, Benjamin J. Resio MD, Daniel J. Boffa MD, MBA

Objective

Approximately 30% of non–small cell lung cancers will recur after surgery, highlighting a need for additional perioperative therapies. Several recent clinical trials demonstrated a reduction in non–small cell lung cancer recurrence with the use of neoadjuvant chemoimmunotherapy. Recognizing that trial results may not always be replicated in the general population, our objective was to evaluate perioperative outcomes of immunotherapy in the real-world setting.

Methods

Adult patients diagnosed with clinical stage I to III non–small cell lung cancer in the National Cancer Database between 2018 and 2022 were included. Perioperative outcomes were evaluated in the following groups: neoadjuvant chemoimmunotherapy, neoadjuvant chemotherapy, or neoadjuvant chemoradiotherapy.

Results

Overall, 3956 patients were identified, including 1051 treated with neoadjuvant chemoimmunotherapy (33.2%), 1590 treated with chemotherapy (40.1%), and 1315 treated with neoadjuvant chemoradiotherapy (26.5%). The pneumonectomy rate after induction chemoimmunotherapy was 6.2%, which was lower than after chemotherapy (10.0%, P = .001) but similar to after chemoradiotherapy (7.9%, P = .11). Postoperative 90-day mortality among patients receiving chemoimmunotherapy was less than 1.0%, which was lower than both chemotherapy (2.0%, P < .001) and chemoradiotherapy (3.5%, P < .001). Nodal downstaging was seen in 43.9% of patients receiving chemoimmunotherapy. The pathologic complete response rate was 30.2%, which was higher than chemotherapy (9.1%, P < .001) but comparable to chemoradiotherapy (26.8%, P = .13). Results from adjusted logistic regressions were consistent with findings of unadjusted analyses.

Conclusions

Real-world outcomes suggest that the reassuring safety and impressive downstaging effect of neoadjuvant chemoimmunotherapy seen in clinical trials can be reproduced in the general population with non–small cell lung cancer. Further study to understand the impact of perioperative chemoimmunotherapy in the real-world setting is justified.

目的：约30%的非小细胞肺癌在手术后会复发，这突出了围手术期治疗的必要性。最近的几项临床试验表明，使用新辅助化疗免疫治疗可以减少非小细胞肺癌的复发。认识到试验结果可能并不总是在一般人群中复制，我们的目标是在现实环境中评估免疫治疗的围手术期结果。方法纳入2018年至2022年国家癌症数据库中诊断为临床I至III期非小细胞肺癌的成年患者。围手术期结果评估如下组：新辅助化疗免疫治疗，新辅助化疗，或新辅助放化疗。结果共发现3956例患者，其中新辅助化疗免疫治疗1051例（33.2%），化疗1590例（40.1%），新辅助放化疗1315例（26.5%）。诱导免疫化疗后全肺切除率为6.2%，低于化疗后（10.0%,P = .001），与放化疗后（7.9%,P = .11）相近。化疗免疫组患者术后90天死亡率低于1.0%，低于化疗组（2.0%,P < 0.001）和放化疗组（3.5%,P < 0.001）。43.9%接受化学免疫治疗的患者出现淋巴结分期降低。病理完全缓解率为30.2%，高于化疗（9.1%,P < .001），但与放化疗（26.8%,P = .13）相当。调整后的逻辑回归结果与未调整分析的结果一致。现实世界的结果表明，临床试验中新辅助化学免疫治疗令人放心的安全性和令人印象深刻的降低分期效果可以在普通非小细胞肺癌患者中重现。进一步研究了解围手术期化疗免疫治疗在现实世界中的影响是合理的。

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引用次数: 0

A novel robotic-assisted lung lobectomy simulation model 一种新型机器人辅助肺叶切除术模拟模型

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.10.006

Carolyn C. Chang MD , Ntemena Kapula MAS , Jake J. Kim BA , Ashley Choi MD , Irmina A. Elliott MD , Douglas Z. Liou MD , Leah M. Backhus MD , Mark F. Berry MD , Joseph B. Shrager MD , Brandon A. Guenthart MD , Natalie S. Lui MD

Objective

Although most thoracic surgery programs seek robotic-competent partners, more than one half of graduating residents report needing more training. We aimed to develop a reproducible, high-fidelity model that serves as an effective training tool for surgeons at all levels.

Methods

Porcine heart-lung blocks were prepped for a left upper lobectomy and cannulated to distend the vasculature using an artificial blood substitute capable of simulating bleeding. A linear actuator was positioned beneath a platform to simulate a heartbeat, and a da Vinci Xi robotic system (Intuitive Surgical) was docked above it. Participants performed 3 key steps of a left upper lobectomy, then evaluated fidelity of model features and training value using the Likert scale. Pre- and postsimulation confidence were reported (institutional review board approval no. 76506).

Results

Among 20 participants, 15 were trainees (75%) and 5 were faculty (25%). Trainees reported a median of 26 bedside (interquartile range, 15-48) and 5 console cases (interquartile range, 3-30). Faculty experience ranged from <5 to >20 years. The model was rated highly for fidelity, with 100% (n = 9) of features receiving a Likert score ≥4 from faculty, with stapling rated highest (5.0 ± 0.0). Trainees rated 89% of features ≥4, with stapling (4.7 ± 0.4) and lung tissue handling (4.7 ± 0.5) rated highest. Both groups rated the simulation as highly valuable, with trainee confidence significantly improving postsimulation (2.5-3.9, P = .0014).

Conclusions

The model was rated highly for fidelity and value by both trainees and faculty, and significantly improved trainee confidence. This model offers an effective and reproducible training tool for individual program implementation.

虽然大多数胸外科项目都在寻找有能力的机器人合作伙伴，但超过一半的毕业住院医师报告需要更多的培训。我们的目标是开发一个可重复的、高保真的模型，作为各级外科医生的有效培训工具。方法采用模拟出血的人工血液代用品插管扩张血管，为左上肺叶切除术预备孢素心肺阻滞。一个线性执行器被放置在一个平台的下面来模拟心跳，一个达芬奇Xi机器人系统（Intuitive Surgical）被停靠在它的上面。参与者完成左上叶切除术的3个关键步骤，然后使用Likert量表评估模型特征的保真度和训练价值。报告了模拟前后的置信度(机构审查委员会批准号：76506)。结果20名参与者中，学员15人（75%），教师5人（25%）。受训者报告的中位数为26例床边病例（四分位数范围15-48）和5例控制台病例（四分位数范围3-30）。教师经验从5年到20年不等。该模型的保真度评价很高，100% （n = 9）的特征得到教师的Likert评分≥4分，其中钉接评分最高（5.0±0.0）。学员对89%的特征评分≥4，其中装订（4.7±0.4）和肺组织处理（4.7±0.5）评分最高。两组都认为模拟非常有价值，学员的信心在模拟后显著提高（2.5-3.9,P = 0.0014）。结论学员和教师对该模型的保真度和价值评价较高，显著提高了学员的自信心。该模型为个别项目的实施提供了有效且可重复的培训工具。

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引用次数: 0

Real-world use of adjuvant nivolumab among patients with esophageal and gastroesophageal junction cancer at a large integrated health system 在一个大型综合医疗系统中，在食管癌和胃食管癌患者中实际使用辅助性纳武单抗

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.10.003

Andrea M. Gochi MD, MS , Sydney Jeffs BS , Yun-Yi Hung PhD , Jingrong Yang MA , Tony Wang PharmD, JD , Gary Okano PhD , Lisa Rosenblatt MD, MPH , Reginald Villacorta PhD , Jeffrey B. Velotta MD

Objectives

To assess real-world use of adjuvant nivolumab in patients with esophageal/gastroesophageal junction cancer.

Methods

This was a retrospective, non-interventional cohort study of electronic health record data in the Kaiser Permanente Northern California cancer registry (June 1, 2020, to October 31, 2024). Index was chemoradiation therapy date between December 1, 2020, and August 31, 2023, with 6 months baseline and ≥12 months’ follow-up. Included patients were aged ≥18 years at index; had stage II/III esophageal/gastroesophageal junction cancer; were receiving chemoradiation within the index period; had evidence of local disease after neoadjuvant chemoradiation; and were classified as Eastern Cooperative Oncology Group performance score 0-1 at index. Patient demographic and clinical characteristics, as well as clinical and patient journey outcomes, were extracted from electronic medical records, confirmed by chart review. Descriptive statistics describe outcomes with Kaplan-Meier method used for time-to-event outcomes.

Results

Included patients (n = 44; median age 66.0 years; interquartile range, 61.5-73.0 years) were followed for median 19.1 months (interquartile range, 10.6-25.3 months) from nivolumab first dose. Median overall survival was not reached. The 24-month overall survival rate was 72.3% (95% confidence interval, 58.7%-89.1%). Median disease-free survival was 20.8 months, and median distant metastases-free survival was 23.7 months (95% confidence interval, 13.0-not reached). All patients underwent minimally invasive esophagectomy and had R0 resection status. Median time from index to nivolumab initiation was 165 days (interquartile range, 138.5-194.0 days). Median duration of nivolumab treatment was 322 days (interquartile range, 148.5-364.0 days); 52.3% of patients completed 1 year of nivolumab treatment.

Conclusions

This study demonstrates survival benefits of adjuvant nivolumab in line with clinical studies.

目的评估纳武单抗在食管/胃食管结癌患者中的实际应用。方法：这是一项回顾性、非介入性队列研究，研究对象是Kaiser Permanente北加州癌症登记处（2020年6月1日至2024年10月31日）的电子健康记录数据。指标为2020年12月1日至2023年8月31日的放化疗日期，基线6个月，随访≥12个月。纳入的患者在指数时年龄≥18岁；II/III期食管/胃食管交界处癌；在指标期内接受放化疗；新辅助放化疗后有局部病变的证据；按指标分为东方合作肿瘤集团绩效评分0-1。从电子病历中提取患者人口统计和临床特征，以及临床和患者旅程结果，并通过图表审查加以确认。描述性统计用Kaplan-Meier方法描述事件时间结果。结果纳入的患者（n = 44，中位年龄66.0岁，四分位数范围61.5-73.0岁）从纳武单抗首次给药开始，随访中位19.1个月（四分位数范围10.6-25.3个月）。中位总生存期未达到。24个月总生存率为72.3%（95%可信区间，58.7%-89.1%）。中位无病生存期为20.8个月，中位无远处转移生存期为23.7个月（95%置信区间为13.0-未达到）。所有患者均行微创食管切除术，R0切除状态。从指数到纳武单抗启动的中位时间为165天（四分位数范围为138.5-194.0天）。纳武单抗治疗的中位持续时间为322天（四分位数范围为148.5-364.0天）；52.3%的患者完成了1年的纳武单抗治疗。结论：本研究证实了辅助纳武单抗的生存获益与临床研究一致。

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引用次数: 0

Influence of patient engagement technology on reported perioperative experiences of patients undergoing lung resection 患者参与技术对肺切除术患者围手术期经验的影响

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.09.044

Frank Gleason MD, MSPH , Benjamin Wei MD , James Donahue MD

Objectives

Patient engagement technologies (PETs) are web-based platforms that provide a means to collect patient-reported outcomes (PROs) as well as guide patients through their surgical journey. The optimal method for collecting PROs is unknown. PROs are an important measure of health care quality We sought to describe the experience of patients undergoing lung resection at our institution using an app-based PET platform.

Methods

Patients undergoing elective lung resection surgery from 2019 to 2023 who enrolled with a PET were identified. Patients received educational content; health checks; and surveys, including the Patient-Reported Outcomes Measurement Information System Global-10 and EuroQOL 5 Dimension surveys. Descriptive statistics were employed to determine utilization and initial observations.

Results

We enrolled 952 patients who underwent lung resection, of whom 88% (838 out of 952) activated the PET and completed the setup survey. More than half (436 out of 838) of patients were women and 68% (229 out of 335) had adequate health literacy. Preoperative Patient-Reported Outcomes Measurement Information System Global-10 and EuroQOL 5 Dimension surveys were completed by 73% (613 out of 838), whereas 37% (309 out of 838) completed an inpatient health check and 39% (325 out of 838) completed a 1-month follow-up survey. Overall, 91% (179 out of 196) reported the PET improved their confidence in postoperative self-care and as a result 86% (169 out of 196) reported feeling less worried about their surgical journey. Use of the PET allowed 39% (77 out of 196) to avoid telephone calls to the hospital care team and 7.6% (15 out of 196) avoided emergency room visits.

Conclusions

Patient engagement technologies provide a way to collect PROs. Among patients who utilize PETs in their perioperative care, there is a reported reduction in telephone calls to providers and emergency room visits, promotion of empowerment in self-care, and reduction of anxiety.

患者参与技术（pet）是一种基于网络的平台，它提供了一种收集患者报告结果（PROs）的方法，并指导患者完成手术过程。收集PROs的最佳方法尚不清楚。PROs是衡量医疗质量的重要指标。我们试图使用基于应用程序的PET平台来描述在我们机构接受肺切除术的患者的体验。方法选取2019年至2023年接受择期肺切除手术的PET入组患者。患者接受教育内容；健康检查;和调查，包括患者报告的结果测量信息系统Global-10和EuroQOL 5维度调查。采用描述性统计来确定利用率和初始观察值。我们招募了952例接受肺切除术的患者，其中88%（952例中的838例）激活了PET并完成了设置调查。超过一半（838名患者中有436名）是女性，68%（335名患者中有229名）具备足够的卫生知识。术前患者报告的结果测量信息系统Global-10和EuroQOL 5维度调查完成了73%（838人中有613人），而37%（838人中有309人）完成了住院健康检查，39%（838人中有325人）完成了1个月的随访调查。总的来说，91%（196人中有179人）报告PET提高了他们对术后自我护理的信心，结果86%（196人中有169人）报告对手术过程的担忧减少了。使用PET允许39%（196人中77人）避免打电话给医院护理小组，7.6%（196人中15人）避免去急诊室。结论患者参与技术提供了一种收集赞成意见的方法。在围手术期护理中使用pet的患者中，有报告称减少了给提供者的电话和急诊室就诊，促进了自我护理的授权，并减少了焦虑。

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引用次数: 0

Achieving and maintaining superior postoperative outcomes with an optimized recovery after thoracic surgery protocol 通过优化胸外科手术后的恢复方案，实现并维持良好的术后结果

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.08.018

Dao Minh Nguyen MD, MSc, FRCSC, FACS, Ahmed Alnajar MD, MSc, MPH, Mehmed Akcin PhD, Nestor Villamizar MD

Objective

Protocol optimization to improve postoperative outcomes is a key component of enhanced recovery after surgery program. The aim of this study is to determine the long-term impact of protocol optimization on postoperative outcomes of robotic pulmonary anatomic resections.

Methods

A retrospective analysis of a prospectively maintained database was performed. All elective robotic anatomic pulmonary resections between February 1, 2018, and December 31, 2023, were included and stratified into original Enhanced Recovery After Thoracic Surgery (ERATS) - group A (February 1, 2018, to December 31, 2019, n = 184) and optimized ERATS - group B (January 1, 2020, to December 31, 2023, n = 557). Propensity-score matching yielded highly comparable cohorts for outcome analysis. Data included demographics, operative details, postoperative outcomes (hospital length of stay [LOS], postoperative opioid use, 30-day complications), patient-reported subjective pain, and cost-savings resulting from reducing observed LOS versus expected LOS on the basis of Medicare Severity Diagnosis-Related Group classification and estimated institution per-diem cost of $1100.00.

Results

Of the 732 eligible patients, 499 were matched with 173 to group A and 326 group B. Protocol optimization was associated with significant improvement of postoperative outcomes: shorter LOS, greater percentages of postoperative day 1 discharge, substantial less opioid requirements with increasing number of opioid-free postdischarges, and greater cost-savings either collectively or per individual DRGs attributable to the reduction of LOS. Annual auditing of the optimized ERATS cohort demonstrated consistent improvements in key metrics over time.

Conclusions

Successful ERATS protocol optimization and maintenance was associated with durable and significantly superior postoperative outcomes along with greater cost-savings attributable to a reduction of LOS in patients undergoing elective robotic pulmonary anatomic resections.

目的优化方案以改善术后预后是提高术后恢复的关键组成部分。本研究的目的是确定方案优化对机器人肺解剖切除术术后结果的长期影响。方法对前瞻性维护数据库进行回顾性分析。纳入2018年2月1日至2023年12月31日期间所有选择性机器人解剖性肺切除术，并将其分层为原始胸腔手术后增强恢复(ERATS) - A组（2018年2月1日至2019年12月31日，n = 184）和优化ERATS - B组（2020年1月1日至2023年12月31日，n = 557）。倾向得分匹配产生了高度可比性的结果分析队列。数据包括人口统计学、手术细节、术后结果（住院时间[LOS]、术后阿片类药物使用、30天并发症）、患者报告的主观疼痛，以及根据医疗严重程度诊断相关组分类和估计机构每日费用1100美元减少观察到的LOS与预期LOS所节省的成本。结果在732例符合条件的患者中，499例与173例A组和326例b组相匹配，方案优化与术后结果的显著改善相关：更短的LOS，更高的术后第1天出院百分比，随着无阿片类药物出院人数的增加，阿片类药物需求大幅减少，以及由于LOS减少而导致的集体或个人DRGs的更大成本节约。经过优化的ERATS队列的年度审计表明，随着时间的推移，关键指标持续改善。结论成功的ERATS方案优化和维护与持久且显著的术后结果相关，同时由于选择性机器人肺解剖切除术患者的LOS减少而节省了更大的成本。

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引用次数: 0

Role of aortic distensibility and stiffness in ascending thoracic aneurysm outcomes 主动脉扩张和僵硬度在胸升动脉瘤预后中的作用

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.10.013

Axel Gomez MD, William Carroway MD, Nipam Raval BA, Liang Ge PhD, Marko Boskovski MD, MHS, MPH, Elaine E. Tseng MD

Objective

Ascending thoracic aortic aneurysms pose a risk of acute dissection. Although diameter guides elective repair, complications often occur below surgical thresholds. Aortic distensibility and stiffness have been proposed as alternative risk markers. We aimed to evaluate the association of deformation indices with all-cause mortality in patients with dilated aortas and ascending thoracic aortic aneurysms.

Methods

Retrospective study of patients with ascending aortic diameter ≥4.0 cm who had a multiphasic electrocardiogram-gated computed tomography angiogram within 3 years of death or between 2021 and 2024. Diameter- and area-based distensibility and stiffness indices were calculated 3 cm above the annulus using dynamic aortic measurements across the cardiac cycle. Differences by mortality status and aortic valve phenotype were assessed using the Wilcoxon rank-sum test.

Results

We included 319 veterans with median age of 75 years (interquartile range, 7.0 years), of whom 35 (11.0%) died within 3 years. Aortic diameter was larger in the mortality group (4.50 vs 4.40 cm; P = .005). Bicuspid aortic valve was present in 12 patients (3.8%). No differences in diameter-based distensibility (0.56 vs 0.64 × 10⁻⁶ cm²/dyne; P = .38) or stiffness index (23.5 vs 23.5; P = .34) were observed by mortality status. Patients with bicuspid aortic valve had higher unadjusted distensibility (1.23 vs 0.63 × 10⁻⁶ cm²/dyne; P = .046) and lower stiffness index (12.5 vs 24.4; P = .05) compared with tricuspid valves. Area-based metrics were similar.

Conclusions

Aortic distensibility and stiffness index were not associated with all-cause mortality. Deformation indices varied by valve morphology in unadjusted analyses but were attenuated after adjustment. Further studies are needed to evaluate aortic deformation indices with regard to ascending thoracic aortic aneurysm risk stratification.

目的探讨胸升主动脉瘤存在急性夹层的危险。虽然直径指导选择性修复，但并发症经常发生在手术阈值以下。主动脉扩张和僵硬被认为是另一种危险标志。我们的目的是评估变形指标与扩张主动脉和上升胸主动脉瘤患者全因死亡率的关系。方法回顾性研究升主动脉直径≥4.0 cm且在死亡3年内或2021 - 2024年间进行了多相心电图门控计算机断层摄影血管造影的患者。在环以上3cm处，通过动态主动脉测量，计算直径和面积为基础的扩张性和刚度指数。使用Wilcoxon秩和检验评估死亡率状况和主动脉瓣表型的差异。结果纳入319例退伍军人，中位年龄75岁（四分位数差7.0岁），其中35例（11.0%）在3年内死亡。死亡组的主动脉直径较大（4.50 vs 4.40 cm; P = 0.005）。12例（3.8%）存在双尖瓣主动脉瓣。基于直径的扩张率（0.56 vs 0.64 × 10−6 cm2/dyne, P = 0.38）或刚度指数（23.5 vs 23.5, P = 0.34）与死亡状态没有差异。与三尖瓣相比，二尖瓣主动脉瓣患者具有更高的未调节扩张性（1.23 vs 0.63 × 10−6 cm2/dyne, P = 0.046）和更低的僵硬指数（12.5 vs 24.4, P = 0.05）。基于区域的指标也是类似的。结论主动脉膨胀性和僵硬指数与全因死亡率无相关性。在未调整的分析中，变形指数随阀门形态的变化而变化，但调整后变形指数减弱。需要进一步的研究来评估主动脉变形指标与胸主动脉瘤上升风险分层的关系。

{"title":"Role of aortic distensibility and stiffness in ascending thoracic aneurysm outcomes","authors":"Axel Gomez MD, William Carroway MD, Nipam Raval BA, Liang Ge PhD, Marko Boskovski MD, MHS, MPH, Elaine E. Tseng MD","doi":"10.1016/j.xjon.2025.10.013","DOIUrl":"10.1016/j.xjon.2025.10.013","url":null,"abstract":"<div><h3>Objective</h3><div>Ascending thoracic aortic aneurysms pose a risk of acute dissection. Although diameter guides elective repair, complications often occur below surgical thresholds. Aortic distensibility and stiffness have been proposed as alternative risk markers. We aimed to evaluate the association of deformation indices with all-cause mortality in patients with dilated aortas and ascending thoracic aortic aneurysms.</div></div><div><h3>Methods</h3><div>Retrospective study of patients with ascending aortic diameter ≥4.0 cm who had a multiphasic electrocardiogram-gated computed tomography angiogram within 3 years of death or between 2021 and 2024. Diameter- and area-based distensibility and stiffness indices were calculated 3 cm above the annulus using dynamic aortic measurements across the cardiac cycle. Differences by mortality status and aortic valve phenotype were assessed using the Wilcoxon rank-sum test.</div></div><div><h3>Results</h3><div>We included 319 veterans with median age of 75 years (interquartile range, 7.0 years), of whom 35 (11.0%) died within 3 years. Aortic diameter was larger in the mortality group (4.50 vs 4.40 cm; <em>P</em> = .005). Bicuspid aortic valve was present in 12 patients (3.8%). No differences in diameter-based distensibility (0.56 vs 0.64 × 10<sup>−6</sup> cm<sup>2</sup>/dyne; <em>P</em> = .38) or stiffness index (23.5 vs 23.5; <em>P</em> = .34) were observed by mortality status. Patients with bicuspid aortic valve had higher unadjusted distensibility (1.23 vs 0.63 × 10<sup>−6</sup> cm<sup>2</sup>/dyne; <em>P</em> = .046) and lower stiffness index (12.5 vs 24.4; <em>P</em> = .05) compared with tricuspid valves. Area-based metrics were similar.</div></div><div><h3>Conclusions</h3><div>Aortic distensibility and stiffness index were not associated with all-cause mortality. Deformation indices varied by valve morphology in unadjusted analyses but were attenuated after adjustment. Further studies are needed to evaluate aortic deformation indices with regard to ascending thoracic aortic aneurysm risk stratification.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"28 ","pages":"Pages 13-23"},"PeriodicalIF":1.9,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145697922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Septal myectomy for obstructive hypertrophic cardiomyopathy: Comparison of outcomes of the transapical beating-heart and transaortic on-pump approaches 中隔肌切除术治疗梗阻性肥厚性心肌病：经心尖搏动和经主动脉无泵入路的结果比较

IF 1.9

JTCVS open

Pub Date : 2025-12-01 DOI: 10.1016/j.xjon.2025.09.041

Younus Qamar MBBS , Rui Li MD, PhD , Jeffrey B. Geske MD , Jing Fang MD, PhD , Brian D. Lahr MS , Alexander T. Lee BS , Steve R. Ommen MD , Song Wan MD, PhD , Hartzell V. Schaff MD , Xiang Wei MD, PhD

Background

Transaortic on-pump septal myectomy (SM) is the established standard for surgical septal reduction, but transapical beating-heart SM recently has emerged as a less invasive alternative. This study compares the early outcomes of these 2 approaches to performing SM in patients with obstructive hypertrophic cardiomyopathy (oHCM).

Methods

We analyzed the outcomes of 200 consecutive patients undergoing transapical beating-heart myectomy and 200 patients receiving transaortic on-pump myectomy. The primary outcome was procedural success, defined as a peak left ventricular outflow tract (LVOT) gradient <30 mm Hg on predismissal echocardiography. Secondary outcomes included transfusion and postoperative atrial fibrillation rates and intensive care unit (ICU) length of stay.

Results

Both techniques significantly reduced LVOT gradient (median reduction: transapical, 102 mm Hg to 15 mm Hg; transaortic, 88 mm Hg to 12 mm Hg; P < .001 for both). Transapical beating-heart myectomy was associated with a shorter ICU stay (median, 24.0 hours vs 26.0 hours; P < .001), a lower atrial fibrillation rate (9.5% vs 30.0%; P < .001), and fewer transfusions (8.0% vs 22.0%; P < .001) but resulted in a higher incidence of new-onset left bundle branch block (63.8% vs 37.0%; P < .001) and longer postoperative hospital stay (median, 11 days vs 5 days; P < .001), owing mainly to institutional protocols. Overall 30-day mortality was 0.5% (n = 1) in the transapical beating-heart myectomy group and 1.0% (n = 2) in the transaortic on-pump myectomy group (P = .562).

Conclusions

Transapical beating-heart SM provides comparable hemodynamic outcomes to transaortic on-pump myectomy with advantages in ICU recovery time, transfusion rates, and postoperative atrial fibrillation. It may be a viable, less invasive alternative for selected oHCM patients. Further studies, including randomized trials, are needed to assess long-term outcomes.

背景：经主动脉无泵鼻中隔肌切除术（SM）是手术鼻中隔缩小的标准，但最近经根尖心脏搏动SM成为一种侵入性较小的选择。本研究比较了这两种方法对梗阻性肥厚性心肌病（oHCM）患者实施SM的早期结果。方法分析200例经根尖搏动心脏肌瘤切除术和200例经主动脉无泵肌瘤切除术患者的预后。主要转归是手术成功，诊断前超声心动图显示左心室流出道（LVOT）梯度峰值为30mmhg。次要结局包括输血和术后房颤发生率和重症监护病房（ICU）住院时间。结果两种技术均显著降低了LVOT梯度（中位数降低：经根尖，102 mm Hg至15 mm Hg；经主动脉，88 mm Hg至12 mm Hg； P < 001）。经根尖搏动心肌切除术与较短的ICU住院时间（中位数，24.0小时对26.0小时；P < 0.001）、较低的房颤发生率（9.5%对30.0%;P < 0.001）和较少的输血（8.0%对22.0%;P < 0.001）相关，但导致较高的新发左束支传导阻滞发生率（63.8%对37.0%;P < 0.001）和较长的术后住院时间（中位数，11天对5天；P < 0.001），这主要是由于机构方案所致。经心尖搏动肌瘤切除术组30天总死亡率为0.5% (n = 1)，经主动脉无泵肌瘤切除术组30天总死亡率为1.0% (n = 2) （P = 0.562）。结论经根尖心脏搏动术的血流动力学结果与经主动脉无泵心肌切除术相当，在ICU恢复时间、输血率和术后房颤方面具有优势。对于某些oHCM患者，它可能是一种可行的、侵入性较小的替代方法。需要进一步的研究，包括随机试验，来评估长期结果。

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引用次数: 0