JTCVS open最新文献

Objectives

Methods

Results

Conclusions

Objective

We examined the effect of frailty on in-hospital mortality, readmission rates, and hospitalization costs after transcatheter and surgical aortic valve replacement in a population-level cohort.

Methods

The Nationwide Readmissions Database was queried for patients who underwent transcatheter or surgical aortic valve replacement during 2016-2018. Multivariate logistic regression was used to discern independent effects of frailty on outcomes. Kaplan–Meier time-to-event analysis was used to evaluate the effect of frailty on freedom from readmission.

Results

A total of 243,619 patients underwent aortic valve replacement: 142,786 (58.6%) transcatheter aortic valve replacements and 100,833 (41.4%) surgical aortic valve replacements. Frail patients constituted 16,388 (11.5%) and 7251 (7.2%) in the transcatheter aortic valve replacement and surgical aortic valve replacement cohorts, respectively. Compared with nonfrail patients, frail patients had greater in-hospital mortality (transcatheter aortic valve replacement: 3.2% vs 1.1%; surgical aortic valve replacement: 6.1% vs 2.0%; both P < .001), longer length of stay (transcatheter aortic valve replacement: 4 vs 2 days; surgical aortic valve replacement: 13 vs 6 days; P < .001), and greater cost (transcatheter aortic valve replacement: $51,654 vs $44,401; surgical aortic valve replacement: $60,782 vs $40,544; P < .001). Time-to-event analysis showed that frail patients had higher rates of readmission over the calendar year in both transcatheter aortic valve replacement (P < .001) and surgical aortic valve replacement (P < .001) cohorts. This association persisted on adjusted multivariate regression for mortality (transcatheter aortic valve replacement odds ratio [95% CI] 1.98 [1.65-2.37], surgical aortic valve replacement 1.96 [1.60-2.41]), 30-day readmission (transcatheter aortic valve replacement 1.38 [1.27-1.49], surgical aortic valve replacement 1.47 [1.30-1.65]), and 90-day readmission (transcatheter aortic valve replacement 1.41 [1.31-1.52], surgical aortic valve replacement 1.60 [1.43-1.79]) (P < .001 for all).

Conclusions

For patients undergoing transcatheter or surgical aortic valve replacement, frailty is associated with in-hospital mortality, readmission, and higher costs. Further efforts to optimize outcomes for frail patients are warranted.

Objective

We aimed to determine if machine learning can predict acute brain injury and to identify modifiable risk factors for acute brain injury in patients receiving venoarterial extracorporeal membrane oxygenation.

Methods

We included adults (age ≥18 years) receiving venoarterial extracorporeal membrane oxygenation or extracorporeal cardiopulmonary resuscitation in the Extracorporeal Life Support Organization Registry (2009-2021). Our primary outcome was acute brain injury: central nervous system ischemia, intracranial hemorrhage, brain death, and seizures. We used Random Forest, CatBoost, LightGBM, and XGBoost machine learning algorithms (10-fold leave-1-out cross-validation) to predict and identify features most important for acute brain injury. We extracted 65 total features: demographics, pre-extracorporeal membrane oxygenation/on-extracorporeal membrane oxygenation laboratory values, and pre-extracorporeal membrane oxygenation/on-extracorporeal membrane oxygenation settings.

Results

Of 35,855 patients receiving venoarterial extracorporeal membrane oxygenation (nonextracorporeal cardiopulmonary resuscitation) (median age of 57.8 years, 66% were male), 7.7% (n = 2769) experienced acute brain injury. In venoarterial extracorporeal membrane oxygenation (nonextracorporeal cardiopulmonary resuscitation), the area under the receiver operator characteristic curves to predict acute brain injury, central nervous system ischemia, and intracranial hemorrhage were 0.67, 0.67, and 0.62, respectively. The true-positive, true-negative, false-positive, false-negative, positive, and negative predictive values were 33%, 88%, 12%, 67%, 18%, and 94%, respectively, for acute brain injury. Longer extracorporeal membrane oxygenation duration, higher 24-hour extracorporeal membrane oxygenation pump flow, and higher on-extracorporeal membrane oxygenation partial pressure of oxygen were associated with acute brain injury. Of 10,775 patients receiving extracorporeal cardiopulmonary resuscitation (median age of 57.1 years, 68% were male), 16.5% (n = 1787) experienced acute brain injury. The area under the receiver operator characteristic curves for acute brain injury, central nervous system ischemia, and intracranial hemorrhage were 0.72, 0.73, and 0.69, respectively. Longer extracorporeal membrane oxygenation duration, older age, and higher 24-hour extracorporeal membrane oxygenation pump flow were associated with acute brain injury.

Conclusions

In the largest study predicting neurological complications with machine learning in extracorporeal membrane oxygenation, longer extracorporeal membrane oxygenation duration and higher 24-hour pump flow were associated with acute brain injury in nonextracorporeal cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation venoarterial extracorporeal membrane oxygenation.

Introduction

TP53 is a strong tumor suppressor gene; its deactivation contributes to carcinogenesis and influences clinical outcomes. However, the prognostic influence of p53 deactivation on early relapse in patients with surgically resected non–small cell lung cancer remains unclear.

Materials and methods

A cohort of 170 patients with primary stage I through III lung adenocarcinoma (LADC) and lung squamous cell carcinoma who underwent complete resection at Tokyo Medical and Dental University was screened for TP53 mutations using panel testing, and association studies between TP53 mutations and clinical data, including histology and postoperative recurrence, were performed. The association between TP53 mutations and postoperative recurrence was validated using data from 604 patients with MSK-IMPACT from The Cancer Genome Atlas. Additional immunohistochemistry for p53 was performed on some subsets of the Tokyo Medical and Dental University population.

Results

Mutations in TP53 were recurrently observed (35.9%; 61 out of 170) in the Tokyo Medical and Dental University cohort. In the histology-stratified analysis, patients with LADC histology showed TP53 mutations that were associated with poor relapse-free survival (log-rank test; P = .020), whereas patients with lung squamous cell carcinoma histology showed TP53 mutations that were not (P = .99). The poor prognosis of TP53 mutation-positive LADCs was validated in The Cancer Genome Atlas-LADC cohort (log-rank test; P = .0065). Additional immunohistochemistry for p53 in patients with LADC histology in the Tokyo Medical and Dental University cohort showed a significant correlation between TP53 mutations and abnormal IHC pattern of p53 (Cramer's correlation coefficient V = 0.67).

Conclusions

TP53 mutation is a potential marker for worse prognosis in surgically resected LADC; immunohistochemistry for p53 could be a surrogate method to identify patients with LADC with a worse prognosis.

Objective

The pathway to cardiothoracic surgery is often obscure for premedical students and aspiring applicants and requires navigating various known and unknown obstacles. Recognizing the challenges encountered on the path to a career in cardiothoracic surgery in the United States, we present this guide for students interested in the field to maximize success in their premedical, preclinical, and preresidency years.

Methods

This is a joint collaboration between the Thoracic Surgery Residents Association and the Thoracic Surgery Medical Student Association. Drawing from firsthand experiences and insights gathered from numerous student applicants and current surgical residents, a comprehensive guide was constructed for students from the point of undergraduate school to advanced training options, including super-fellowship training.

Results

Several intricacies to cardiothoracic surgery career planning were discussed, including differences between traditional and integrated/fast-track pathways, college and medical school selection, networking, performing during clinical rotations, extracurricular and research activities, building mentorship relationships, and pursuing alternate career and advanced training opportunities.

Conclusions

For premedical students and aspiring applicants, the road to cardiothoracic surgery requires meticulous planning, grit, and thoughtful dedication. This document consolidates firsthand insights and advice from numerous aspiring and matched applicants to serve as a comprehensive guide for students seeking a career in cardiovascular and thoracic surgery.

Objectives

Reprogramming of energy metabolism is a well-established hallmark of cancer, with aerobic glycolysis classically considered a prominent feature. We investigate the heterogeneity in glucose metabolism pathways within resectable primary lung adenocarcinoma and its clinical significance.

Methods

Using The Cancer Genome Atlas data, RNA expressions were extracted from 489 primary lung adenocarcinoma samples. Prognostic influence of glycolytic, aerobic, and mitochondrial markers (monocarboxylate transporter [MCT]4, MCT1, and translocase of outer mitochondrial membrane 20, respectively) was assessed using Kaplan-Meier analysis. Clustering of 35 genes involved in glucose metabolism was performed using the k-means method. The clusters were then analyzed for associations with demographic, clinical, and pathologic variables. Overall survival was assessed using the Kaplan-Meier estimator. Multivariate analysis was performed to assess the independent prognostic value of cluster membership.

Results

Classical statistical approach showed that higher expression of MCT4 was associated with a significantly worse prognosis. Increased expression of translocase of outer mitochondrial membrane 20 was associated with a nonsignificant trend toward better prognosis, and increased expression of MCT1 was associated with a better outcome. Clustering identified 3 major metabolic phenotypes, dominantly hypometabolic, dominantly oxidative, and dominantly mixed oxidative/glycolytic with significantly different pathologic stage distribution and prognosis; mixed oxidative/glycolytic was associated with worse survival. Cluster membership was independently associated with survival.

Conclusions

This study demonstrates the existence of distinct glucose metabolism clusters in resectable lung adenocarcinoma, providing valuable prognostic information. The findings highlight the potential relevance of considering metabolic profiles when designing strategies for reprogramming energy metabolism. Further studies are warranted to validate these findings in different cancer types and populations.

Objective

In patients with non–small cell lung cancer, lymph node assessment is essential for appropriate staging. The intrapulmonary lymph nodes (IPLNs) should be considered when assigning the N stage but are infrequently evaluated in Colombian centers, resulting in understaging that may hinder optimal treatment.

Methods

We conducted a prospective study of IPLN dissection in patients with clinical stage I or II non–small cell lung cancer who underwent surgical resection at 9 institutions in Colombia between 2021 and 2023. IPLN dissection was performed by trained surgeons who collected lymph nodes from fresh specimens after resection and before formalin fixation.

Results

One hundred patients were eligible for the analysis. Their mean age was 67 ± 10.9 years, and 76% were women. Most (74%) had adenocarcinoma, 20% had neuroendocrine tumors, and 6% had squamous cell carcinoma. Successful sampling and histopathologic analysis of at least one IPLN station was obtained in 85% of patients, 9% had upstaging due to positive N2 lymph nodes, and 5% had upstaging due to positive N1 lymph nodes. Among the patients with pN0 or pN1 disease, 3.2% (3 out of 91) were upstaged exclusively due to positive IPLNs.

Conclusions

Fresh-specimen dissection to collect IPLNs is appropriate and feasible to achieve more accurate pathological staging in Colombian lung cancer patients. In clinical N0 patients, IPLN dissection maximizes selection for adjuvant therapy.

Objective

Asian Americans include heterogeneous subpopulations with unique burden as the only racial group with cancer as the leading cause of death. The purpose of the study was to identify differences in clinical stage and survival of patients with lung cancer between Asian Americans and its subgroups relative to other racial groups.

Methods

Patients with lung cancer from 2016 National Cancer Database were divided into East Asian, Southeast Asian, South Asian subgroups based on geographic origins, and a composite Asian American group with White non-Hispanic, Black, and Hispanic comparison groups. Columnar z score analysis with adjusted residuals was employed and the terms underrepresented and overrepresented were utilized to describe significant statistical findings.

Results

A total of 825,448 patients were analyzed. Asian Americans were underrepresented relative to White non-Hispanics in all clinical stages except IIIB and IV. In clinical stage IV, Asian Americans (51.0%), East Asians (47.2%), Southeast Asians (57.4%), and South Asians (52.2%) were overrepresented relative to White non-Hispanics (42.2%) and Southeast Asians were overrepresented relative to East Asians and South Asians. For survival across all stages, Asian Americans were overrepresented relative to White non-Hispanics and Blacks, but in clinical stage IV, Southeast Asians (17.9%) were underrepresented relative to East Asians (26.0%) and South Asians (26.6%).

Conclusions

This is the first study to address lung cancer disparity in Asian American subgroups employing a novel analytical approach. Asian American subgroups demonstrated more advanced lung cancer diagnosis yet higher survival compared with White non-Hispanics, Blacks, and/or Hispanics with differences between subgroups. Interplay of complex factors may contribute to Asian American health disparities.

Objective

Pediatric patients on ventricular assist devices (VAD) are at risk of thromboembolic (TE) complications. Our objective was to identify factors associated with TE events, including the role of initial anticoagulation strategy and device type in the pediatric VAD population.

Methods

This was a retrospective, single-center review (2005-2022) of children who were implanted with paracorporeal pulsatile (PP), paracorporeal continuous (PC), or a combination of devices. Patient- and device-related factors were collected. Kaplan-Meier survival analysis was performed to determine freedom from TE. Cox proportional hazard analysis was conducted to look for factors associated with TE events.

Results

Ninety-five patients included with a median age of 0.9 years (interquartile range, 0.3, 5.4); median weight of 8.4 kg (interquartile range, 4.5, 17.8), and 63.2% with noncongenital heart disease. Device breakdown included 47.4% PC, 24.2% PP, and 23.2% combination of devices. Initial anticoagulation was either heparin (61.5%) or bivalirudin (38.5%). In Kaplan-Meier analysis, unadjusted freedom from a TE event was significantly greater in those who received bivalirudin as their initial anticoagulation strategy (P = .02) and PP VADs (P = .02). In multivariate analysis, initial anticoagulation strategy with bivalirudin (hazard ratio, 0.30; 95% confidence interval, 0.12-0.75, P = .01) was associated with a reduced hazard of TE events, whereas PC device strategy was found to be associated with an increased hazard (hazard ratio, 2.78; 95% confidence interval, 1.12-6.88, P = .03).

Conclusions

This study suggests that PC device strategy and heparin as an initial anticoagulation strategy are associated with increased hazard of TE events. Further research is required to understand the interaction between device type and initial anticoagulation strategy.