JTCVS open最新文献_第3页

Lymphatic vascular invasion: Diagnostic variability and overall survival impact on patients undergoing surgical resection 淋巴管侵犯：诊断变异性和对手术切除患者总体生存的影响

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.08.012

John Varlotto MD , Rick Voland PhD , Negar Rassaei MD , Dani Zander MD , Malcolm M. DeCamp MD , Jai Khatri MD , Yousef Shweihat MD , Kemnasom Nwanwene MD , Maria Tria Tirona MD , Thomas Wright MD , Toni Pacioles MD , Muhammad Jamil MD , Khuram Anwar MD , John Flickinger MD

Objective

The diagnostic criteria of lymphatic vascular invasion have not been standardized. Our investigation assesses the factors associated with lymphatic vascular invasion positive tumors and the impact of lymphatic vascular invasion on overall survival for patients with non–small cell lung cancer undergoing (bi)lobectomy with an adequate node dissection.

Methods

The National Cancer Database was queried from the years 2010 to 2015 to find surgical patients who underwent lobectomy with at least 10 lymph nodes examined (adequate node dissection) and with known lymphatic vascular invasion status. Paired t tests were used to distinguish differences between the patients with and without lymphatic vascular invasion in their specimen. Multivariable analysis was used to determine factors associated with overall survival. Propensity score matching adjusting for overall survival factors was used to determine the lymphatic vascular invasion's overall survival impact by grade, histology, p-T/N/overall stage, and tumor size.

Results

Lymphatic vascular invasion status was reported in 91.6% and positive in 23.4% of 28,842 eligible patients. Academic medical centers, institutions with populations more than 1,000,000, and the mid-Atlantic region reported higher rates of lymphatic vascular invasion positive tumors as well as overall survival compared with other cancer centers. Lymphatic vascular invasion was independently associated with a significant decrement in overall survival as per multivariable analysis and propensity score matching. Propensity score matching demonstrated that lymphatic vascular invasion was associated with a significant decrement in overall survival for all histologies, tumor grades, tumor sizes, and stages, except for more advanced pathologic stages T3/III/N2 and larger tumors greater than 4 cm for which overall survival was trending worse with lymphatic vascular invasion positive.

Conclusions

Lymphatic vascular invasion positive varies based on hospital location/type and population, but it was associated with a decrement in overall survival that was independent of pathologic T/N/overall stage, histology, and tumor grade. Lymphatic vascular invasion must be standardized and considered as a staging variable and should be considered as a sole determinant for prognosis, especially for those with earlier-stage and smaller tumors.

目的淋巴管侵犯的诊断标准尚未统一。我们的调查评估了淋巴管侵犯阳性肿瘤的相关因素，以及淋巴管侵犯对接受（双）肺叶切除术并进行充分结节清扫的非小细胞肺癌患者总生存率的影响。方法查询了2010年至2015年的美国国家癌症数据库，以找到接受肺叶切除术并至少检查了10个淋巴结（充分结节清扫）且已知淋巴管侵犯状态的手术患者。采用配对 t 检验来区分标本中存在和不存在淋巴管侵犯的患者之间的差异。多变量分析用于确定与总生存率相关的因素。根据总生存率因素进行倾向评分匹配调整，以确定淋巴管侵犯对分级、组织学、p-T/N/总分期和肿瘤大小的总生存率的影响。结果在28842例符合条件的患者中，91.6%的患者报告了淋巴管侵犯状态，23.4%的患者报告了阳性。与其他癌症中心相比，学术医疗中心、人口超过100万的机构和大西洋中部地区的淋巴管侵犯阳性肿瘤率和总生存率更高。根据多变量分析和倾向得分匹配，淋巴管侵犯与总生存率的显著下降密切相关。倾向评分匹配显示，淋巴管侵犯与所有组织学、肿瘤分级、肿瘤大小和分期的总生存率显著下降有关，但晚期病理分期T3/III/N2和大于4厘米的较大肿瘤除外，淋巴管侵犯阳性的肿瘤总生存率呈下降趋势。结论淋巴管侵犯阳性因医院位置/类型和人群而异，但它与总生存率下降有关，且与病理T/N/总分期、组织学和肿瘤分级无关。淋巴管侵犯必须标准化，并被视为分期变量，而且应被视为预后的唯一决定因素，尤其是对于早期和较小肿瘤患者。

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引用次数: 0

Alternative discharge destination following lobectomy: Analysis of a national quality improvement database 肺叶切除术后的出院选择：国家质量改进数据库分析

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.06.020

Victoria Yin MD, MPH , Sean C. Wightman MD , Takashi Harano MD , Scott M. Atay MD , Anthony W. Kim MD

Objective

To determine factors significantly associated with alternative discharge destination (ADCD) following lobectomy, including the modified 5-item Frailty Index (mFI-5).

Methods

Patients in the 2017-2020 NSQIP who underwent elective lobectomy and were admitted from home were included, with ADCD defined as a patient who was discharged to any nonhome location. Four multivariable logistic regression models for ADCD were evaluated for predictive power. Model A was created from backward selection of variables significantly associated with ADCD in bivariate analyses, model B was the mFI-5, model C was mFI-5 and a minimally invasive approach, and model D was mFI-5 and age group.

Results

Among the 15,868 patients, 687 (4.3%) experienced ADCD. Model A identified older age, hypertension, dyspnea, history of chronic obstructive pulmonary disease, and increased length of stay as significantly associated with ADCD. A minimally invasive approach was significantly protective of ADCD. Model A had the best predictive power of the models tested (C-statistic = 0.785). Model B, which assessed mFI-5 alone, had fair predictive power (C-statistic = 0.637). Adding surgical approach (C-statistic = 0.673; model C) or age group (C-statistic = 0.682; model D) as independent variables with mFI-5 improved model fit.

Conclusions

Patients who were frail or age >75 years were more likely to have postlobectomy ADCD. Although the variables identified in model A better predict ADCD, consideration of surgical approach or age with mFI-5 can help surgeons anticipate discharge destination following lobectomy.

目的确定与肺叶切除术后替代出院目的地（ADCD）明显相关的因素，包括改良的 5 项虚弱指数（mFI-5）。方法纳入 2017-2020 年 NSQIP 中接受择期肺叶切除术并从家中入院的患者，ADCD 定义为出院到任何非家庭所在地的患者。评估了 ADCD 的四个多变量逻辑回归模型的预测能力。模型 A 是根据双变量分析中与 ADCD 显著相关的变量逆向选择创建的，模型 B 是 mFI-5，模型 C 是 mFI-5 和微创方法，模型 D 是 mFI-5 和年龄组。模型 A 发现年龄较大、高血压、呼吸困难、慢性阻塞性肺病病史和住院时间延长与 ADCD 显著相关。微创方法对 ADCD 有明显保护作用。在所测试的模型中，模型 A 的预测能力最强（C 统计量 = 0.785）。单独评估 mFI-5 的模型 B 预测能力一般（C 统计量 = 0.637）。将手术方式（C-统计量=0.673；模型 C）或年龄组（C-统计量=0.682；模型 D）作为 mFI-5 的自变量可提高模型的拟合度。虽然模型 A 中确定的变量能更好地预测 ADCD，但考虑手术方式或年龄与 mFI-5 可以帮助外科医生预测肺叶切除术后的出院去向。

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引用次数: 0

Repair of acute type A aortic dissection: The simplest solution is not always the best 急性 A 型主动脉断裂的修复最简单的解决方案不一定是最好的解决方案

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.03.004

引用次数: 0

Commentator Discussion: Tricuspid valve surgery for acute infective endocarditis can be performed with very low operative mortality 评论员讨论：三尖瓣手术治疗急性感染性心内膜炎的手术死亡率极低

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.07.008

引用次数: 0

Commentator Discussion: Autonomous Fontan pump: Computational feasibility study 评论员讨论：自主丰坦泵：计算可行性研究

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.07.010

引用次数: 0

Improving prediction accuracy of spread through air spaces in clinical-stage T1N0 lung adenocarcinoma using computed tomography imaging models 利用计算机断层成像模型提高临床期 T1N0 肺腺癌通过气隙扩散的预测准确性

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.07.018

Shihua Dou MD , Zhuofeng Li BS , Zhenbin Qiu MD , Jing Zhang PhD , Yaxi Chen MD , Shuyuan You MD , Mengmin Wang MD , Hongsheng Xie MD , Xiaoxiang Huang MD , Yun Yi Li , Jingjing Liu MD , Yuxin Wen MD , Jingshan Gong PhD , Fanli Peng MD , Wenzhao Zhong PhD , Xuegong Zhang PhD , Lin Yang PhD

Objectives

To develop computed tomography (CT)-based models to increase the prediction accuracy of spread through air spaces (STAS) in clinical-stage T1N0 lung adenocarcinoma.

Methods

Three cohorts of patients with stage T1N0 lung adenocarcinoma (n = 1258) were analyzed retrospectively. Two models using radiomics and deep neural networks (DNNs) were established to predict the lung adenocarcinoma STAS status. For the radiomic models, features were extracted using PyRadiomics, and 10 features with nonzero coefficients were selected using least absolute shrinkage and selection operator regression to construct the models. For the DNN models, a 2-stage (supervised contrastive learning and fine-tuning) deep-learning model, MultiCL, was constructed using CT images and the STAS status as training data. The area under the curve (AUC) was used to verify the predictive ability of both model types for the STAS status.

Results

Among the radiomic models, the linear discriminant analysis model exhibited the best performance, with AUC values of 0.8944 (95% confidence interval [CI], 0.8241-0.9502) and 0.7796 (95% CI, 0.7089-0.8448) for predicting the STAS status on the test and external validation cohorts, respectively. Among the DNN models, MultiCL exhibited the best performance, with AUC values of 0.8434 (95% CI, 0.7580-0.9154) for the test cohort and 0.7686 (95% CI, 0.6991-0.8316) for the external validation cohort.

Conclusions

CT-based imaging models (radiomics and DNNs) can accurately identify the STAS status of clinical-stage T1N0 lung adenocarcinoma, potentially guiding surgical decision making and improving patient outcomes.

方法回顾性分析了三组 T1N0 期肺腺癌患者（n = 1258）。利用放射组学和深度神经网络（DNN）建立了两个模型来预测肺腺癌的 STAS 状态。在放射组学模型中，使用 PyRadiomics 提取特征，并使用最小绝对收缩和选择算子回归法选出 10 个系数不为零的特征来构建模型。对于 DNN 模型，使用 CT 图像和 STAS 状态作为训练数据，构建了一个两阶段（监督对比学习和微调）深度学习模型 MultiCL。结果在放射学模型中，线性判别分析模型表现最佳，其预测测试组和外部验证组 STAS 状态的 AUC 值分别为 0.8944（95% 置信区间 [CI]，0.8241-0.9502）和 0.7796（95% CI，0.7089-0.8448）。结论基于CT的成像模型（放射组学和DNN）可以准确识别临床期T1N0肺腺癌的STAS状态，从而为手术决策提供指导并改善患者预后。

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引用次数: 0

Disparities in mortality rates from aortic aneurysm and dissection by country-level income status and sex 按国家收入水平和性别分列的主动脉瘤和夹层死亡率差异

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.08.004

Makoto Hibino MD, MPH, PhD , Nitish K. Dhingra MD , Raj Verma , Christoph A. Nienaber MD , Bobby Yanagawa MD, PhD , Subodh Verma MD, PhD

Objective

To investigate the impact of national income level and sex on mortality trends from aortic aneurysm and dissection in addition to all aortic disease as a whole.

Methods

Using data from the World Health Organization mortality database, we conducted an analysis of mortality trends from aortic disease between 2000 and 2019, Countries were categorized into middle-income and high-income countries (MICs and HICs) on the basis of income level. Age-standardized and sex-specific age-standardized mortality rates per 100,000 persons, along with male-to-female mortality ratios, were calculated. Trends over the study period were analyzed using joinpoint regression.

Results

Our analysis comprised 29 MICs and 46 HICs, with an average population of 595 million and 1042 million during the observation period. During the observation period, age-standardized mortality rates from aortic disease decreased to 2.21 (2.17-2.25) and 2.28 (2.26-2.30) in MICs and HICs, respectively (average annual percentage change of −0.5% in MICs and −1.8% in HICs, P < .05 for both). However, mortality rates from aortic dissection increased in HICs from 2000 to 2019 (average annual percentage change of 1.3%, P < .001). Mortality from aortic disease, aortic dissection, and aortic aneurysm were male dominant in MICs and HICs but decreasing trends during the observation periods except for aortic dissection in MICs.

Conclusions

We present the contemporary and comprehensive analysis of global socioeconomic status and aortic diseases mortality. Although trends of mortality from aortic diseases are on the decline in both MICs and HICs, there is a striking increase in mortality for aortic dissection, specifically in HICs.

方法利用世界卫生组织死亡率数据库的数据，我们对 2000 年至 2019 年间主动脉疾病的死亡率趋势进行了分析，根据收入水平将国家分为中等收入国家和高收入国家（MICs 和 HICs）。计算了每 10 万人的年龄标准化死亡率和特定性别死亡率，以及男女死亡率比。结果我们的分析包括 29 个中等收入国家和 46 个高收入国家，观察期内的平均人口分别为 5.95 亿和 1.04 亿。在观察期内，中等收入国家和高收入国家的主动脉疾病年龄标准化死亡率分别降至 2.21（2.17-2.25）和 2.28（2.26-2.30）（中等收入国家的年均百分比变化为-0.5%，高收入国家的年均百分比变化为-1.8%，两者的 P 均为 0.05）。然而，从 2000 年到 2019 年，高收入国家的主动脉夹层死亡率有所上升（年均百分比变化为 1.3%，P < .001）。在中等收入国家和高收入国家，主动脉疾病、主动脉夹层和主动脉瘤的死亡率以男性为主，但在观察期内，除中等收入国家的主动脉夹层外，主动脉疾病、主动脉夹层和主动脉瘤的死亡率呈下降趋势。尽管在中等收入国家和高收入国家，主动脉疾病的死亡率呈下降趋势，但主动脉夹层的死亡率却显著上升，尤其是在高收入国家。

{"title":"Disparities in mortality rates from aortic aneurysm and dissection by country-level income status and sex","authors":"Makoto Hibino MD, MPH, PhD , Nitish K. Dhingra MD , Raj Verma , Christoph A. Nienaber MD , Bobby Yanagawa MD, PhD , Subodh Verma MD, PhD","doi":"10.1016/j.xjon.2024.08.004","DOIUrl":"10.1016/j.xjon.2024.08.004","url":null,"abstract":"<div><h3>Objective</h3><div>To investigate the impact of national income level and sex on mortality trends from aortic aneurysm and dissection in addition to all aortic disease as a whole.</div></div><div><h3>Methods</h3><div>Using data from the World Health Organization mortality database, we conducted an analysis of mortality trends from aortic disease between 2000 and 2019, Countries were categorized into middle-income and high-income countries (MICs and HICs) on the basis of income level. Age-standardized and sex-specific age-standardized mortality rates per 100,000 persons, along with male-to-female mortality ratios, were calculated. Trends over the study period were analyzed using joinpoint regression.</div></div><div><h3>Results</h3><div>Our analysis comprised 29 MICs and 46 HICs, with an average population of 595 million and 1042 million during the observation period. During the observation period, age-standardized mortality rates from aortic disease decreased to 2.21 (2.17-2.25) and 2.28 (2.26-2.30) in MICs and HICs, respectively (average annual percentage change of −0.5% in MICs and −1.8% in HICs, <em>P</em> < .05 for both). However, mortality rates from aortic dissection increased in HICs from 2000 to 2019 (average annual percentage change of 1.3%, <em>P</em> < .001). Mortality from aortic disease, aortic dissection, and aortic aneurysm were male dominant in MICs and HICs but decreasing trends during the observation periods except for aortic dissection in MICs.</div></div><div><h3>Conclusions</h3><div>We present the contemporary and comprehensive analysis of global socioeconomic status and aortic diseases mortality. Although trends of mortality from aortic diseases are on the decline in both MICs and HICs, there is a striking increase in mortality for aortic dissection, specifically in HICs.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"21 ","pages":"Pages 224-238"},"PeriodicalIF":0.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142553452","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Trends in utilization, timing, and outcomes of thoracic endovascular repair for type B aortic dissection in the United States 美国 B 型主动脉夹层胸腔内血管修复术的使用趋势、时机和结果

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.07.016

Troy Coaston BS , Oh Jin Kwon MD , Amulya Vadlakonda BS , Jeffrey Balian , Nam Yong Cho BS , Saad Mallick MD , Christian de Virgilio MD , Peyman Benharash MD

Background

Aortic dissection is the most common acute aortic syndrome in the United States. Type B aortic dissection (TBAD) can be managed medically, through open surgical repair, or with thoracic endovascular repair (TEVAR). The present study sought to assess contemporary trends in the use and timing of TEVAR.

Methods

Adult nonelective TBAD admissions were identified in the 2010 to 2020 Nationwide Readmissions Database. Patients were categorized as medical management (Medical Management), TEVAR at initial hospitalization (Early), or TEVAR during readmission (Delayed). Multivariable models were developed to assess associations with clinical outcomes and resource utilization.

Results

Of 85,753 patients, 8.7% underwent TEVAR at index hospitalization (Early). From 2010 to 2020, the proportion undergoing TEVAR decreased significantly (from 11.3% to 9.6%; nptrend < .001), while the proportion of TEVAR at a subsequent hospitalization increased (from 13.0% to 21.6%; nptrend < .001). Compared to Medical Management, the Early group was younger (median. 63 [interquartile range (IQR), 52-74] years vs 69 [IQR, 57-81] years), and more frequently privately insured (27.7% vs 17.5%; P < .001). Following adjustment, the Early group had a reduced odds of mortality (adjusted odds ratio [aOR], 0.56; 95% confidence interval [CI], 0.48-0.66) and increased hospitalization costs (β = +$50,000; 95% CI, $48,000-$53,000). Among 4267 TEVAR patients with available procedure timing data, 15.7% were categorized as Delayed. The Early and Delayed groups did not differ in terms of demographics. The Delayed group had a decreased likelihood of major adverse events (aOR, 0.50; 95% CI, 0.39-0.64); however, this did not affect 90-day cumulative hospitalization costs (β = +$2700; 95% CI, -$5000-$11,000, ref: Early).

Conclusions

This study suggests changes to TBAD management in both treatment modality and TEVAR timing. Focused analysis on the timing and long-term costs of TEVAR are needed to optimize care delivery.

背景主动脉夹层是美国最常见的急性主动脉综合征。B型主动脉夹层（TBAD）可通过药物、开放手术修复或胸腔内血管修复（TEVAR）进行治疗。本研究旨在评估 TEVAR 的使用和时机的当代趋势。方法从 2010 年至 2020 年全国再入院数据库中确定了非选择性 TBAD 成人入院患者。患者被分为医疗管理（Medical Management）、首次住院时进行 TEVAR（Early）或再入院时进行 TEVAR（Delayed）。结果在85753名患者中，8.7%的患者在首次住院时（早期）接受了TEVAR。从 2010 年到 2020 年，接受 TEVAR 的比例显著下降（从 11.3% 降至 9.6%；nptrend <；.001），而在随后的住院中接受 TEVAR 的比例则有所上升（从 13.0% 升至 21.6%；nptrend <；.001）。与医疗管理相比，早期组患者更年轻（中位数：63[四分位间距（IQ）：.001]）。63[四分位数间距 (IQR)，52-74]岁 vs 69 [四分位数间距 (IQR, 57-81]岁]），并且更多私人投保（27.7% vs 17.5%；P < .001）。经调整后，早期组的死亡率降低（调整后的几率比 [aOR]，0.56；95% 置信区间 [CI]，0.48-0.66），住院费用增加（β = +50,000美元；95% CI，48,000-53,000美元）。在4267例有手术时间数据的TEVAR患者中，15.7%被归为延迟组。早期组和延迟组在人口统计学方面没有差异。延迟组发生重大不良事件的可能性降低（aOR，0.50；95% CI，0.39-0.64）；但这并不影响90天的累计住院费用（β = +2700美元；95% CI，-5000-11000美元，参考：早期）。需要对 TEVAR 的时机和长期成本进行重点分析，以优化医疗服务。

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引用次数: 0

Autonomous Fontan pump: Computational feasibility study 自主丰坦泵：计算可行性研究

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.07.003

Mark D. Rodefeld MD , Timothy Conover PhD , Richard Figliola PhD , Mike Neary MS , Guruprasad Giridharan PhD , Artem Ivashchenko MEng , Edward M. Bennett PhD

Objective

After Fontan palliation, patients with single-ventricle physiology are committed to chronic circulatory inefficiency for the duration of their lives. This is due in large part to the lack of a subpulmonary ventricle. A low-pressure rise cavopulmonary assist device can address the subpulmonary deficit and offset the Fontan paradox. We investigated the feasibility of a Fontan pump that is self-powered by tapping reserve pressure energy in the systemic arterial circulation.

Methods

A double-inlet, double-outlet rotary pump was designed to augment Fontan flow through the total cavopulmonary connection. Pump power is supplied by a systemic arterial shunt and radial turbine, with a closed-loop shunt return to the common atrium (Q_P:Q_S 1:1). Computational fluid dynamic analysis and lumped parameter modeling of pump impact on the Fontan circulation was performed.

Results

Findings indicate that a pump that can augment all 4 limbs of total cavopulmonary connection flow (superior vena cava/inferior vena cava inflow; left pulmonary artery/right pulmonary artery outflow) using a systemic arterial shunt powered turbine at a predicted cavopulmonary pressure rise of +2.5 mm Hg. Systemic shunt flow is 1.43 lumped parameter model, 22% cardiac output. Systemic venous pressure is reduced by 1.4 mm Hg with improved ventricular preload and cardiac output.

Conclusions

It may be possible to tap reserve pressure energy in the systemic circulation to improve Fontan circulatory efficiency. Further studies are warranted to optimize, fabricate, and test pump designs for hydraulic performance and hemocompatibility. Potential benefits of an autonomous Fontan pump include durable physiologic shift toward biventricular health, freedom from external power, autoregulating function and exercise responsiveness, and improved quality and duration of life.

目的单心室生理学患者在接受丰坦（Fontan）姑息治疗后，终生处于慢性循环功能低下状态。这在很大程度上是由于缺乏肺下心室。低压上升腔肺辅助装置可以解决肺下腔不足的问题，并抵消丰坦悖论。我们研究了通过利用全身动脉循环中的储备压力能量自供电的丰坦泵的可行性。方法设计了一个双入口、双出口旋转泵，通过全腔肺连接增强丰坦血流。泵的动力由全身动脉分流器和径向涡轮提供，并通过闭环分流器返回普通心房（QP:QS 1:1）。结果研究结果表明，使用全身动脉分流驱动涡轮的泵可以增加腔肺总连接的所有四肢血流（上腔静脉/下腔静脉流入；左肺动脉/右肺动脉流出），而预测的腔肺压力升高为 +2.5 mm Hg。全身分流量为 1.43 个集合参数模型，心输出量为 22%。全身静脉压降低了 1.4 毫米汞柱，心室前负荷和心输出量得到改善。有必要开展进一步研究，以优化、制造和测试泵的水力性能和血液相容性。自主丰坦泵的潜在益处包括：向双心室健康的持久生理转变、摆脱外部动力、自动调节功能和运动反应能力，以及提高生活质量和延长寿命。

{"title":"Autonomous Fontan pump: Computational feasibility study","authors":"Mark D. Rodefeld MD , Timothy Conover PhD , Richard Figliola PhD , Mike Neary MS , Guruprasad Giridharan PhD , Artem Ivashchenko MEng , Edward M. Bennett PhD","doi":"10.1016/j.xjon.2024.07.003","DOIUrl":"10.1016/j.xjon.2024.07.003","url":null,"abstract":"<div><h3>Objective</h3><div>After Fontan palliation, patients with single-ventricle physiology are committed to chronic circulatory inefficiency for the duration of their lives. This is due in large part to the lack of a subpulmonary ventricle. A low-pressure rise cavopulmonary assist device can address the subpulmonary deficit and offset the Fontan paradox. We investigated the feasibility of a Fontan pump that is self-powered by tapping reserve pressure energy in the systemic arterial circulation.</div></div><div><h3>Methods</h3><div>A double-inlet, double-outlet rotary pump was designed to augment Fontan flow through the total cavopulmonary connection. Pump power is supplied by a systemic arterial shunt and radial turbine, with a closed-loop shunt return to the common atrium (Q<sub>P</sub>:Q<sub>S</sub> 1:1). Computational fluid dynamic analysis and lumped parameter modeling of pump impact on the Fontan circulation was performed.</div></div><div><h3>Results</h3><div>Findings indicate that a pump that can augment all 4 limbs of total cavopulmonary connection flow (superior vena cava/inferior vena cava inflow; left pulmonary artery/right pulmonary artery outflow) using a systemic arterial shunt powered turbine at a predicted cavopulmonary pressure rise of +2.5 mm Hg. Systemic shunt flow is 1.43 lumped parameter model, 22% cardiac output. Systemic venous pressure is reduced by 1.4 mm Hg with improved ventricular preload and cardiac output.</div></div><div><h3>Conclusions</h3><div>It may be possible to tap reserve pressure energy in the systemic circulation to improve Fontan circulatory efficiency. Further studies are warranted to optimize, fabricate, and test pump designs for hydraulic performance and hemocompatibility. Potential benefits of an autonomous Fontan pump include durable physiologic shift toward biventricular health, freedom from external power, autoregulating function and exercise responsiveness, and improved quality and duration of life.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"21 ","pages":"Pages 257-266"},"PeriodicalIF":0.0,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141693539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Out of the ice age: Preservation of cardiac allografts with a reusable 10 °C cooler 走出冰河时代用可重复使用的 10 °C 冷却器保存心脏同种异体移植物

JTCVS open

Pub Date : 2024-10-01 DOI: 10.1016/j.xjon.2024.08.005

John M. Trahanas MD , Timothy Harris MD , Mark Petrovic MS , Anthony Dreher MPA , Chetan Pasrija MD , Stephen A. DeVries PA-C , Swaroop Bommareddi MD , Brian Lima MD , Chen Chia Wang BSc , Michael Cortelli BS , Avery Fortier BSc , Kaitlyn Tracy MD , Elizabeth Simonds BA , Clifton D. Keck , Shelley R. Scholl RN , Hasan Siddiqi MD , Kelly Schlendorf MD , Matthew Bacchetta MD , Ashish S. Shah MD

Objective

Static cold storage with ice has been the mainstay of cardiac donor preservation. Early preclinical data suggest that allograft preservation at 10 °C may be beneficial. We tested this hypothesis by using a static 10 °C storage device to preserve and transport cardiac allografts.

Methods

In total, 52 allografts were recovered between July 2023 and March 2024 and transported using a 10 °C storage cooler. Results were compared to a 3:1 propensity match of allografts transported on ice. Patients were excluded for the following reasons: dual viscera transplant, previous heart transplant, complex congenital heart disease, or allograft injury during procurement.

Results

Among the 10 °C cooler cohort, median total ischemic time was 222 minutes at 10 °C versus 193 minutes on ice (P < .0001). Intraoperative change in lactate was statistically lower at 10 °C (3.6 vs 5.1 mmol/L, P = .0016). Cardiac index score was greater in 10 °C cooler hearts at 24 (3.2 vs 3.0, P = .016) and 72 hours (3.3 vs 2.9, P = .037), despite similar vasoactive inotrope scores. There was no difference in severe primary graft dysfunction (1.9 vs 2.6%, P > .99). 10 °C hearts demonstrated less change in lactate but no difference in vasoactive inotrope scores or cardiac index. In hearts with extended ischemic time, delta lactate was lower in 10 °C cooler hearts. There was no statistical difference in outcomes for donor hearts >40 years old.

Conclusions

This is an early experience of static preservation in a 10 °C cooler. Postoperative allograft function was excellent, and lactate profiles lower in those allografts with extended ischemic times. Static cold storage targeting 10 °C may offer an inexpensive method for extended heart preservation. Further investigation is needed to assess long-term outcomes of 10 °C storage.

目的用冰块进行静态冷藏一直是保存心脏供体的主要方法。早期的临床前数据表明，10 °C下保存同种异体移植物可能是有益的。方法在 2023 年 7 月至 2024 年 3 月期间，共回收了 52 例同种异体移植物，并使用 10 °C冷藏箱进行运输。结果与在冰上运输的同种异体移植物进行了 3:1 的倾向性匹配比较。患者因以下原因被排除在外：双脏器移植、既往心脏移植、复杂的先天性心脏病或异体移植物在采集过程中受伤。结果在10 °C冷藏箱队列中，10 °C中位总缺血时间为222分钟，而冰上为193分钟（P < .0001）。据统计，术中乳酸的变化在 10°C 时更低（3.6 vs 5.1 mmol/L，P = .0016）。尽管血管活性肌力剂评分相似，但在 24 小时（3.2 vs 3.0，P = .016）和 72 小时（3.3 vs 2.9，P = .037）时，10 °C温度较低心脏的心脏指数评分更高。严重的原发性移植物功能障碍没有差异（1.9% vs 2.6%，P = .99）。10 °C心脏的乳酸变化较小，但血管活性肌力评分或心脏指数没有差异。在缺血时间延长的心脏中，10 °C低温心脏的乳酸δ值较低。结论这是使用 10 °C 低温箱进行静态保存的早期经验。术后同种异体移植物功能良好，缺血时间较长的同种异体移植物乳酸含量较低。以 10 °C 为目标的静态冷藏可能是延长心脏保存时间的一种廉价方法。需要进一步调查以评估 10 °C冷藏的长期效果。

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引用次数: 0