JTCVS open最新文献_第5页

Commentator Discussion: Outcomes of surgical valve replacements for radiation-induced valvulopathy

JTCVS open

Pub Date : 2025-02-01 DOI: 10.1016/j.xjon.2024.11.006

引用次数: 0

Zero superior vena cava injury lead extraction with rotational system: A contemporary experience

JTCVS open

Pub Date : 2025-02-01 DOI: 10.1016/j.xjon.2024.11.010

Iverson E. Williams BS, Omar M. Sharaf MD, Ryan Azarrafiy MD, MPH, Daniel Demos MD, Eric I. Jeng MD, MBA, Kirsten A. Freeman MD, John R. Spratt MD, Thomas M. Beaver MD, MPH

Background

Transvenous cardiac implantable electronic device (CIED) lead extraction (TLE) is susceptible to superior vena cava (SVC) injury and can be performed in the operating room (OR) or electrophysiology lab via a mechanical device or laser-powered extraction. This study reflects a contemporary experience of mechanical right-left rotational extraction by cardiac surgeons in the OR.

Methods

We conducted a retrospective single-center review of adult (age ≥18 years) TLE cases performed by cardiac surgeons between 2019 and 2021. Leads were extracted via a transvenous mechanical right-left controlled-rotation system in the OR under general anesthesia with transesophageal echocardiographic guidance. Procedural success was defined as complete extraction of all leads without major complications, based on the Heart Rhythm Society's 2017 guidelines.

Results

A total of 210 leads were extracted from 104 patients, including 72 males (69%). The mean patient age was 63.8 ± 16.7 years, and 26 patients (25%) had undergone prior sternotomy. The most common indication for CIED extraction was infection (69%; n = 72). Removed CIEDs included single-chamber defibrillators (46%; n = 48), pacemakers (33%; n = 34), and cardiac resynchronization therapy devices (21%; n = 22). The mean age of the oldest extracted lead by patient was 9.79 ± 7.25 years. Procedural success was obtained in 95% of cases (99/104). The remaining cases included distal lead fracture (n = 3), inferior vena cava laceration necessitating sternotomy (n = 1), and tricuspid valve damage requiring delayed valve replacement (n = 1). There were zero SVC injuries, and procedure-related mortality was 0%.

Conclusions

Mechanical, controlled-rotation TLE is effective and can be performed safely without SVC injury. TLE by cardiac surgeons in the OR enables rapid conversion to sternotomy in the event of major complications.

{"title":"Zero superior vena cava injury lead extraction with rotational system: A contemporary experience","authors":"Iverson E. Williams BS, Omar M. Sharaf MD, Ryan Azarrafiy MD, MPH, Daniel Demos MD, Eric I. Jeng MD, MBA, Kirsten A. Freeman MD, John R. Spratt MD, Thomas M. Beaver MD, MPH","doi":"10.1016/j.xjon.2024.11.010","DOIUrl":"10.1016/j.xjon.2024.11.010","url":null,"abstract":"<div><h3>Background</h3><div>Transvenous cardiac implantable electronic device (CIED) lead extraction (TLE) is susceptible to superior vena cava (SVC) injury and can be performed in the operating room (OR) or electrophysiology lab via a mechanical device or laser-powered extraction. This study reflects a contemporary experience of mechanical right-left rotational extraction by cardiac surgeons in the OR.</div></div><div><h3>Methods</h3><div>We conducted a retrospective single-center review of adult (age ≥18 years) TLE cases performed by cardiac surgeons between 2019 and 2021. Leads were extracted via a transvenous mechanical right-left controlled-rotation system in the OR under general anesthesia with transesophageal echocardiographic guidance. Procedural success was defined as complete extraction of all leads without major complications, based on the Heart Rhythm Society's 2017 guidelines.</div></div><div><h3>Results</h3><div>A total of 210 leads were extracted from 104 patients, including 72 males (69%). The mean patient age was 63.8 ± 16.7 years, and 26 patients (25%) had undergone prior sternotomy. The most common indication for CIED extraction was infection (69%; n = 72). Removed CIEDs included single-chamber defibrillators (46%; n = 48), pacemakers (33%; n = 34), and cardiac resynchronization therapy devices (21%; n = 22). The mean age of the oldest extracted lead by patient was 9.79 ± 7.25 years. Procedural success was obtained in 95% of cases (99/104). The remaining cases included distal lead fracture (n = 3), inferior vena cava laceration necessitating sternotomy (n = 1), and tricuspid valve damage requiring delayed valve replacement (n = 1). There were zero SVC injuries, and procedure-related mortality was 0%.</div></div><div><h3>Conclusions</h3><div>Mechanical, controlled-rotation TLE is effective and can be performed safely without SVC injury. TLE by cardiac surgeons in the OR enables rapid conversion to sternotomy in the event of major complications.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"23 ","pages":"Pages 171-175"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143465000","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

Recommendation letter language for applicants selected to interview at integrated cardiothoracic surgery residency: A qualitative assessment by gender

JTCVS open

Pub Date : 2025-02-01 DOI: 10.1016/j.xjon.2024.12.001

Siddharth Yarlagadda BA , Jason J. Han MD , Jacqueline M. Soegaard Ballester MD, MBMI , Caroline O’Brien MS , Justin T. Clapp PhD, MPH , Marisa Cevasco MD, MPH

Objective

Cardiothoracic (CT) surgery remains a male-dominated specialty. Letters of recommendation (LORs) influence trainee selection and are vulnerable to biases. We aimed to qualitatively assess differences in LORs to integrated residency on the basis of applicant gender.

Methods

LORs for applicants who interviewed at a single integrated CT residency program during one cycle were selected and pooled by applicant gender. Gendered and identifying references were redacted. Letters were analyzed by a thematic analysis approach and managed through NVivo software.

Results

Thirty LORs across 8 male applicants and 43 LORs across 11 female applicants were analyzed. There was no noticeable difference between the frequency of positive attributes assigned to each gender. Research accomplishments was the most emphasized competency, with no gender-based difference identified. LORs for female applicants tended to be longer and include stronger positive adjectives. For male applicants, descriptions of external recognition were almost exclusively via mention of scholarships or research, whereas female applicants were more likely to receive word-of-mouth recognition. Letter writers often attested to male applicants’ commitment to CT surgery, whereas female applicants received more commentary around effective patient care.

Conclusions

Letters for men tended to focus on research accolades and career commitment, whereas letters for women were longer and more likely to emphasize patient care or faculty endorsement. Future studies may discern whether this phenomenon reflects stronger applicant-writer relationships for female applicants or a disadvantageous approach by letter writers for female applicants that relies on subjective rationale.

{"title":"Recommendation letter language for applicants selected to interview at integrated cardiothoracic surgery residency: A qualitative assessment by gender","authors":"Siddharth Yarlagadda BA , Jason J. Han MD , Jacqueline M. Soegaard Ballester MD, MBMI , Caroline O’Brien MS , Justin T. Clapp PhD, MPH , Marisa Cevasco MD, MPH","doi":"10.1016/j.xjon.2024.12.001","DOIUrl":"10.1016/j.xjon.2024.12.001","url":null,"abstract":"<div><h3>Objective</h3><div>Cardiothoracic (CT) surgery remains a male-dominated specialty. Letters of recommendation (LORs) influence trainee selection and are vulnerable to biases. We aimed to qualitatively assess differences in LORs to integrated residency on the basis of applicant gender.</div></div><div><h3>Methods</h3><div>LORs for applicants who interviewed at a single integrated CT residency program during one cycle were selected and pooled by applicant gender. Gendered and identifying references were redacted. Letters were analyzed by a thematic analysis approach and managed through NVivo software.</div></div><div><h3>Results</h3><div>Thirty LORs across 8 male applicants and 43 LORs across 11 female applicants were analyzed. There was no noticeable difference between the frequency of positive attributes assigned to each gender. Research accomplishments was the most emphasized competency, with no gender-based difference identified. LORs for female applicants tended to be longer and include stronger positive adjectives. For male applicants, descriptions of external recognition were almost exclusively via mention of scholarships or research, whereas female applicants were more likely to receive word-of-mouth recognition. Letter writers often attested to male applicants’ commitment to CT surgery, whereas female applicants received more commentary around effective patient care.</div></div><div><h3>Conclusions</h3><div>Letters for men tended to focus on research accolades and career commitment, whereas letters for women were longer and more likely to emphasize patient care or faculty endorsement. Future studies may discern whether this phenomenon reflects stronger applicant-writer relationships for female applicants or a disadvantageous approach by letter writers for female applicants that relies on subjective rationale.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"23 ","pages":"Pages 379-385"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143465079","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

Pulmonary artery enlargement as a predictor of long-term prognosis in patients with resected early-stage non–small cell lung cancer

JTCVS open

Pub Date : 2025-02-01 DOI: 10.1016/j.xjon.2024.11.009

Megumi Nishikubo MD , Sanae Kuroda MD , Nanase Haga MD , Yuki Nishioka MD , Nahoko Shimizu MD, PhD , Yuko Fukuda MD, PhD , Wataru Nishio MD, PhD

Objectives

Although several studies have highlighted the potential prognostic value of computed tomography-measured pulmonary artery enlargement in various respiratory diseases, the long-term outcomes following lung cancer surgery remain unexplored. This study aimed to assess the predictive value of pulmonary artery enlargement for overall survival in patients with completely resected non–small cell lung cancer.

Methods

We retrospectively identified patients with pathological Tis-1cN0M0 non–small cell lung cancer who underwent complete resection between 2013 and 2018 in our hospital. We reviewed the routine preoperative computed tomography images and measured the pulmonary artery diameter at the bifurcation (PA) and the ascending aorta diameter (A) to calculate the PA/A ratio. Based on a PA/A threshold of 0.8, patients were categorized into high- and low-ratio groups, and their overall survival and cumulative incidence of cause-specific deaths were compared after propensity score matching.

Results

Of the 319 included patients, 116 were categorized into the high-ratio group and 203 into the low-ratio group. After propensity score matching, overall survival was significantly worse in the high-ratio group than in the low-ratio group (5-year overall survival: 89.4% vs 96.2%; P = .006). The high-ratio group had a significantly higher incidence of death not related to lung cancer than the low-ratio group (P = .01).

Conclusions

In patients with resected early-stage non–small cell lung cancer, those with preoperatively pulmonary artery enlargement had a poorer overall survival than those without, possibly attributed to a higher non-lung cancer-related death incidence. Measuring the preoperative PA/A ratio might be a useful tool for risk stratification, and selecting sublobar resection for these patients could improve the long-term prognosis.

{"title":"Pulmonary artery enlargement as a predictor of long-term prognosis in patients with resected early-stage non–small cell lung cancer","authors":"Megumi Nishikubo MD , Sanae Kuroda MD , Nanase Haga MD , Yuki Nishioka MD , Nahoko Shimizu MD, PhD , Yuko Fukuda MD, PhD , Wataru Nishio MD, PhD","doi":"10.1016/j.xjon.2024.11.009","DOIUrl":"10.1016/j.xjon.2024.11.009","url":null,"abstract":"<div><h3>Objectives</h3><div>Although several studies have highlighted the potential prognostic value of computed tomography-measured pulmonary artery enlargement in various respiratory diseases, the long-term outcomes following lung cancer surgery remain unexplored. This study aimed to assess the predictive value of pulmonary artery enlargement for overall survival in patients with completely resected non–small cell lung cancer.</div></div><div><h3>Methods</h3><div>We retrospectively identified patients with pathological Tis-1cN0M0 non–small cell lung cancer who underwent complete resection between 2013 and 2018 in our hospital. We reviewed the routine preoperative computed tomography images and measured the pulmonary artery diameter at the bifurcation (PA) and the ascending aorta diameter (A) to calculate the PA/A ratio. Based on a PA/A threshold of 0.8, patients were categorized into high- and low-ratio groups, and their overall survival and cumulative incidence of cause-specific deaths were compared after propensity score matching.</div></div><div><h3>Results</h3><div>Of the 319 included patients, 116 were categorized into the high-ratio group and 203 into the low-ratio group. After propensity score matching, overall survival was significantly worse in the high-ratio group than in the low-ratio group (5-year overall survival: 89.4% vs 96.2%; <em>P</em> = .006). The high-ratio group had a significantly higher incidence of death not related to lung cancer than the low-ratio group (<em>P</em> = .01).</div></div><div><h3>Conclusions</h3><div>In patients with resected early-stage non–small cell lung cancer, those with preoperatively pulmonary artery enlargement had a poorer overall survival than those without, possibly attributed to a higher non-lung cancer-related death incidence. Measuring the preoperative PA/A ratio might be a useful tool for risk stratification, and selecting sublobar resection for these patients could improve the long-term prognosis.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"23 ","pages":"Pages 266-275"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143465187","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

Potential advantage of magnetic resonance imaging in detecting thoracic wall infiltration in pleural mesothelioma: A retrospective single-center analysis

JTCVS open

Pub Date : 2025-02-01 DOI: 10.1016/j.xjon.2024.10.012

Isabel Barreto MD , Sabine Franckenberg MD , Thomas Frauenfelder MD , Isabelle Opitz MD , Olivia Lauk MD

Objectives

Thoracic wall infiltration in pleural mesothelioma determines the extent of resection and can be an important prognostic factor. Currently, standardized imaging for restaging after neoadjuvant systemic therapy comprises contrast-enhanced computed tomography or positron emission tomography. Additional thoracic magnetic resonance imaging could better discriminate chest wall infiltration preoperatively and increase staging accuracy. For this reason, the added benefit of magnetic resonance imaging was evaluated at our center.

Methods

A retrospective analysis of the extended imaging protocol was performed from July 2018 to March 2024, including a descriptive analysis for the patient's sex, age, tobacco consumption, asbestos exposure, histological subtype, TNM stage, Modified Response Evaluation Criteria for Solid Tumors in solid tumors, and number of neoadjuvant therapy cycles. Preoperative restaging included routine imaging and magnetic resonance imaging. After histological diagnosis of pleural mesothelioma, neoadjuvant therapy was conducted, followed by intended macroscopic complete resection, with intraoperative biopsies of suspicious chest wall lesions. Computed tomography and magnetic resonance imaging results were compared with intraoperative biopsies.

Results

Twenty-six patients (mean age, 65.50 years, 11.50% female) with operable pleural mesothelioma were included. Of the 11 patients with histologically proven chest wall infiltration, 10 (90.91%) had a cT-stage 3 or greater and 4 (36.36%) underwent surgery that resulted in an R2 resection. Thoracic magnetic resonance imaging showed a high sensitivity (90.91%) for the detection of chest wall infiltration, especially when compared with the computed tomography scan (9.09%).

Conclusions

With the adjunctive use of magnetic resonance imaging, we demonstrated a higher sensitivity for detection of chest wall infiltration compared with conventional imaging before surgery. This may improve patient selection for surgery. Nevertheless, larger studies are required to confirm these results.

{"title":"Potential advantage of magnetic resonance imaging in detecting thoracic wall infiltration in pleural mesothelioma: A retrospective single-center analysis","authors":"Isabel Barreto MD , Sabine Franckenberg MD , Thomas Frauenfelder MD , Isabelle Opitz MD , Olivia Lauk MD","doi":"10.1016/j.xjon.2024.10.012","DOIUrl":"10.1016/j.xjon.2024.10.012","url":null,"abstract":"<div><h3>Objectives</h3><div>Thoracic wall infiltration in pleural mesothelioma determines the extent of resection and can be an important prognostic factor. Currently, standardized imaging for restaging after neoadjuvant systemic therapy comprises contrast-enhanced computed tomography or positron emission tomography. Additional thoracic magnetic resonance imaging could better discriminate chest wall infiltration preoperatively and increase staging accuracy. For this reason, the added benefit of magnetic resonance imaging was evaluated at our center.</div></div><div><h3>Methods</h3><div>A retrospective analysis of the extended imaging protocol was performed from July 2018 to March 2024, including a descriptive analysis for the patient's sex, age, tobacco consumption, asbestos exposure, histological subtype, TNM stage, Modified Response Evaluation Criteria for Solid Tumors in solid tumors, and number of neoadjuvant therapy cycles. Preoperative restaging included routine imaging and magnetic resonance imaging. After histological diagnosis of pleural mesothelioma, neoadjuvant therapy was conducted, followed by intended macroscopic complete resection, with intraoperative biopsies of suspicious chest wall lesions. Computed tomography and magnetic resonance imaging results were compared with intraoperative biopsies.</div></div><div><h3>Results</h3><div>Twenty-six patients (mean age, 65.50 years, 11.50% female) with operable pleural mesothelioma were included. Of the 11 patients with histologically proven chest wall infiltration, 10 (90.91%) had a cT-stage 3 or greater and 4 (36.36%) underwent surgery that resulted in an R2 resection. Thoracic magnetic resonance imaging showed a high sensitivity (90.91%) for the detection of chest wall infiltration, especially when compared with the computed tomography scan (9.09%).</div></div><div><h3>Conclusions</h3><div>With the adjunctive use of magnetic resonance imaging, we demonstrated a higher sensitivity for detection of chest wall infiltration compared with conventional imaging before surgery. This may improve patient selection for surgery. Nevertheless, larger studies are required to confirm these results.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"23 ","pages":"Pages 318-325"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143465192","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

Pediatric cardiac surgical site infections: A single-center quality improvement initiative 儿童心脏手术部位感染：单中心质量改进倡议。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.08.013

Nhat Chau HBSc , Crystal Tran HBSc, CCRP , Megan Clarke MN, RN, CIC , Jennifer Kilburn MN, RN , Cecilia St. George-Hyslop MEd, RN, CNCCPC , Diana Young RN , Sandra L. Merklinger MN-NP, PhD , Erica Mosolanczki MN-NP , Vivian Trinder MN-NP , Jill O'Hare MN-NP , Karen Clarke RN , Kate McCormick MScN, RN , Rachel D. Vanderlaan MD, PhD, FRCSC

Objective

Pediatric cardiac surgery site infections (SSI) represent significant morbidity. Our institution reported elevated SSI rates of 3.48 per 100 cases over a 5-year period above target rates of 2.5 per 100 cases. Therefore, as a quality improvement initiative, we implemented interventions with the goal of decreasing SSI rates by 30%.

Methods

Pediatric cardiovascular surgery patients (January 2021 to August 2023) who had SSI within 30 days of index operation were included (n = 1514) based on the National Healthcare Safety Network definition. Descriptive statistics were used to compare our preintervention cohort (pre-IV) (January 2021 to April 2022; n = 753) and postintervention cohort (post-IV) (May 2022 to August 2023; n = 761).

Results

In the post-IV cohort, we found a significant decrease in total SSI (1.97 SSIs per 100 cases [15 out of 761]) versus pre-IV (3.85 SSIs per 100 cases [29 out of 753]), demonstrating a 48% reduction (P = .029). In our post-IV cohort, there was a significant reduction in superficial SSIs (pre-IV, 3.19 SSIs per 100 cases [24 out of 753] vs post-IV, 1.58 SSIs out of 100 cases [12 out of 761]; P = .04). Wounds presenting at 1 to 3 weeks were also reduced in our post-IV cohort (pre-IV, 2.66 SSIs per100 cases [20 out of 753] vs post-IV, 0.66 SSIs per 100 cases [5 out of 761]; P = .002). A significant reduction in SSIs in nonneonates was also noted (pre-IV, 2.79 SSIs per 100 cases [21 out of 753] vs post-IV, 0.92 SSIs per 100 cases [7 out of 761]; P = .007). Additionally, there was a significant reduction in SSIs associated with the Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery 1 mortality category (P = .033) and the number of readmissions in the post-IV cohort (P = .042).

Conclusions

A new surgical site dressing and multidisciplinary surveillance plan effectively reduced the overall burden of SSI rates at our institution. Future studies will address risk factors in specific subpopulations to further reduce SSIs at our institution.

目的：小儿心脏手术部位感染（SSI）发病率高。我们的机构报告，在5年期间，每100例SSI发生率为3.48例，高于每100例2.5例的目标率。因此，作为一项质量改进倡议，我们实施了干预措施，目标是将SSI率降低30%。方法：根据国家医疗安全网络定义，纳入2021年1月至2023年8月在指数手术后30天内发生SSI的儿科心血管手术患者（n = 1514）。描述性统计用于比较我们的干预前队列（pre-IV）(2021年1月至2022年4月；n = 753)和干预后队列（iv后）(2022年5月至2023年8月；n = 761)。结果：在静脉注射后队列中，我们发现总SSI（1.97 / 100例SSI[761 / 15]）与静脉注射前（3.85 / 100例SSI[753 / 29]）相比显著下降，降低了48% （P = 0.029）。在我们的静脉注射后队列中，浅表ssi显著减少(静脉注射前，每100例3.19例ssi[753 / 24]，静脉注射后，每100例1.58例ssi [761 / 12]；p = .04)。在我们的静脉注射后队列中，1至3周出现的伤口也减少了(静脉注射前，每100例2.66例ssi[753例中的20例]，而静脉注射后，每100例0.66例ssi[761例中的5例]；p = .002)。非新生儿ssi的显著减少也被注意到(静脉注射前，每100例2.79例ssi[753 / 21]，静脉注射后，每100例0.92例ssi [761 / 7]；p = .007)。此外，与胸外科学会-欧洲心胸外科协会先天性心脏手术1死亡率类别（P = 0.033）和iv后队列再入院人数（P = 0.042）相关的ssi显著减少。结论：新的手术部位包扎和多学科监测计划有效地减轻了我院SSI率的总体负担。未来的研究将解决特定亚群的危险因素，以进一步减少我们机构的ssi。

{"title":"Pediatric cardiac surgical site infections: A single-center quality improvement initiative","authors":"Nhat Chau HBSc , Crystal Tran HBSc, CCRP , Megan Clarke MN, RN, CIC , Jennifer Kilburn MN, RN , Cecilia St. George-Hyslop MEd, RN, CNCCPC , Diana Young RN , Sandra L. Merklinger MN-NP, PhD , Erica Mosolanczki MN-NP , Vivian Trinder MN-NP , Jill O'Hare MN-NP , Karen Clarke RN , Kate McCormick MScN, RN , Rachel D. Vanderlaan MD, PhD, FRCSC","doi":"10.1016/j.xjon.2024.08.013","DOIUrl":"10.1016/j.xjon.2024.08.013","url":null,"abstract":"<div><h3>Objective</h3><div>Pediatric cardiac surgery site infections (SSI) represent significant morbidity. Our institution reported elevated SSI rates of 3.48 per 100 cases over a 5-year period above target rates of 2.5 per 100 cases. Therefore, as a quality improvement initiative, we implemented interventions with the goal of decreasing SSI rates by 30%.</div></div><div><h3>Methods</h3><div>Pediatric cardiovascular surgery patients (January 2021 to August 2023) who had SSI within 30 days of index operation were included (n = 1514) based on the National Healthcare Safety Network definition. Descriptive statistics were used to compare our preintervention cohort (pre-IV) (January 2021 to April 2022; n = 753) and postintervention cohort (post-IV) (May 2022 to August 2023; n = 761).</div></div><div><h3>Results</h3><div>In the post-IV cohort, we found a significant decrease in total SSI (1.97 SSIs per 100 cases [15 out of 761]) versus pre-IV (3.85 SSIs per 100 cases [29 out of 753]), demonstrating a 48% reduction (<em>P</em> = .029). In our post-IV cohort, there was a significant reduction in superficial SSIs (pre-IV, 3.19 SSIs per 100 cases [24 out of 753] vs post-IV, 1.58 SSIs out of 100 cases [12 out of 761]; <em>P</em> = .04). Wounds presenting at 1 to 3 weeks were also reduced in our post-IV cohort (pre-IV, 2.66 SSIs per100 cases [20 out of 753] vs post-IV, 0.66 SSIs per 100 cases [5 out of 761]; <em>P</em> = .002). A significant reduction in SSIs in nonneonates was also noted (pre-IV, 2.79 SSIs per 100 cases [21 out of 753] vs post-IV, 0.92 SSIs per 100 cases [7 out of 761]; <em>P</em> = .007). Additionally, there was a significant reduction in SSIs associated with the Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery 1 mortality category (<em>P</em> = .033) and the number of readmissions in the post-IV cohort (<em>P</em> = .042).</div></div><div><h3>Conclusions</h3><div>A new surgical site dressing and multidisciplinary surveillance plan effectively reduced the overall burden of SSI rates at our institution. Future studies will address risk factors in specific subpopulations to further reduce SSIs at our institution.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"22 ","pages":"Pages 438-447"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704585/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142959772","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

Randomized study of temporary diaphragm pacing for enhanced recovery after surgery in cardiac surgery patients at risk of prolonged mechanical ventilation 临时膈肌起搏对延长机械通气风险的心脏手术患者术后恢复增强的随机研究。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.031

Jessica R. Hungate MD , Raymond P. Onders MD , Mohammad El Diasty MD, PhD , Yasir Abu-Omar MD, DPhil , Rakesh C. Arora MD, PhD , Cristian Baeza MD , Yakov Elgudin MD, PhD , Kelsey Gray MD , Alan Markowitz MD , Marc Pelletier MD , Igo B. Ribeiro MD , Pablo Ruda Vega MD , Gregory D. Rushing MD , Joseph F. Sabik III MD

Objective

Prolonged mechanical ventilation after cardiac surgery significantly increases morbidity and mortality. The aim of this study is to establish the role of diaphragmatic pacing to decrease mechanical ventilation burden in high-risk patients undergoing cardiac surgery.

Methods

This is a prospective, randomized trial of temporary diaphragmatic pacing electrode use in patients undergoing cardiac surgery (NCT04899856). Prognostic enrichment strategy was used to identify patients at higher risk of prolonged mechanical ventilation by having inclusion criteria of prior open cardiac surgery, left ventricular ejection fraction less than 30%, history of stroke, intra-aortic balloon pump, or history of chronic obstructive pulmonary disease. Two electrodes were placed in each hemidiaphragm intraoperatively. On arrival to the intensive care unit, patients were randomized to immediate diaphragmatic pacing or standard of care.

Results

Forty patients received implants, with 19 in the treatment group and 21 in the standard of care group. Only 1 patient in the treatment group was on mechanical ventilation at 24 hours versus 4 patients in the standard of care group, resulting in a relative risk reduction of 71% being on mechanical ventilation at 24 hours postoperatively. Predictive enrichment strategy was used to identify patients most likely to respond to therapy of diaphragmatic pacing. In this analysis, median time on mechanical ventilation was 17.7 hours (interquartile range, 8.3-23.4) for the 15 patients in the standard of care group and 9.4 hours (interquartile range, 7.14-12.5) for the 13 patients in the treatment group, for an improvement of 8 hours with diaphragm pacing (P < .05).

Conclusions

Temporary diaphragmatic pacing improved weaning from mechanical ventilation by 8 hours with a significant reduction of prolonged mechanical ventilation. Multicenter randomized trials confirming diaphragmatic pacing as an Enhanced Recovery After Surgery tool to decrease mechanical ventilation may reduce length of stay, postoperative infections, and additive costs.

目的：心脏手术后延长机械通气时间明显增加其发病率和死亡率。本研究的目的是确定膈起搏在减少高危心脏手术患者机械通气负担中的作用。方法：这是一项前瞻性随机试验，研究临时膈起搏电极在心脏手术患者中的应用（NCT04899856）。预后富集策略通过纳入既往心脏直视手术、左室射血分数小于30%、卒中史、主动脉内球囊泵或慢性阻塞性肺疾病史等标准来识别延长机械通气高风险患者。术中在半膈各放置两个电极。到达重症监护室后，患者被随机分配到立即膈肌起搏或标准护理组。结果：40例患者接受种植体治疗，治疗组19例，标准护理组21例。治疗组24小时机械通气1例，标准护理组4例，术后24小时机械通气相对风险降低71%。预测富集策略用于识别最有可能对膈肌起搏治疗有反应的患者。在本分析中，标准护理组的15例患者中位机械通气时间为17.7小时（四分位数范围8.3-23.4），治疗组的13例患者中位机械通气时间为9.4小时（四分位数范围7.14-12.5），膈肌起搏延长了8小时(P结论：临时膈肌起搏使机械通气脱机时间缩短了8小时，延长机械通气时间显著减少。多中心随机试验证实膈肌起搏作为一种增强术后恢复的工具，可以减少机械通气，减少住院时间、术后感染和附加费用。

{"title":"Randomized study of temporary diaphragm pacing for enhanced recovery after surgery in cardiac surgery patients at risk of prolonged mechanical ventilation","authors":"Jessica R. Hungate MD , Raymond P. Onders MD , Mohammad El Diasty MD, PhD , Yasir Abu-Omar MD, DPhil , Rakesh C. Arora MD, PhD , Cristian Baeza MD , Yakov Elgudin MD, PhD , Kelsey Gray MD , Alan Markowitz MD , Marc Pelletier MD , Igo B. Ribeiro MD , Pablo Ruda Vega MD , Gregory D. Rushing MD , Joseph F. Sabik III MD","doi":"10.1016/j.xjon.2024.09.031","DOIUrl":"10.1016/j.xjon.2024.09.031","url":null,"abstract":"<div><h3>Objective</h3><div>Prolonged mechanical ventilation after cardiac surgery significantly increases morbidity and mortality. The aim of this study is to establish the role of diaphragmatic pacing to decrease mechanical ventilation burden in high-risk patients undergoing cardiac surgery.</div></div><div><h3>Methods</h3><div>This is a prospective, randomized trial of temporary diaphragmatic pacing electrode use in patients undergoing cardiac surgery (NCT04899856). Prognostic enrichment strategy was used to identify patients at higher risk of prolonged mechanical ventilation by having inclusion criteria of prior open cardiac surgery, left ventricular ejection fraction less than 30%, history of stroke, intra-aortic balloon pump, or history of chronic obstructive pulmonary disease. Two electrodes were placed in each hemidiaphragm intraoperatively. On arrival to the intensive care unit, patients were randomized to immediate diaphragmatic pacing or standard of care.</div></div><div><h3>Results</h3><div>Forty patients received implants, with 19 in the treatment group and 21 in the standard of care group. Only 1 patient in the treatment group was on mechanical ventilation at 24 hours versus 4 patients in the standard of care group, resulting in a relative risk reduction of 71% being on mechanical ventilation at 24 hours postoperatively. Predictive enrichment strategy was used to identify patients most likely to respond to therapy of diaphragmatic pacing. In this analysis, median time on mechanical ventilation was 17.7 hours (interquartile range, 8.3-23.4) for the 15 patients in the standard of care group and 9.4 hours (interquartile range, 7.14-12.5) for the 13 patients in the treatment group, for an improvement of 8 hours with diaphragm pacing (<em>P</em> < .05).</div></div><div><h3>Conclusions</h3><div>Temporary diaphragmatic pacing improved weaning from mechanical ventilation by 8 hours with a significant reduction of prolonged mechanical ventilation. Multicenter randomized trials confirming diaphragmatic pacing as an Enhanced Recovery After Surgery tool to decrease mechanical ventilation may reduce length of stay, postoperative infections, and additive costs.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"22 ","pages":"Pages 76-84"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704535/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142959776","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

Surgical management of giant cell arteritis of the proximal aorta 近主动脉巨细胞性动脉炎的外科治疗。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.08.017

Motahar Hosseini MD , Alberto Pochettino MD , Joseph A. Dearani MD , Alejandra Castro-Varela MD , Hartzell V. Schaff MD , Katherine S. King MS , Richard C. Daly MD , Kevin L. Greason MD , Juan A. Crestanello MD , Gabor Bagameri MD , Nishant Saran MBBS

Objective

Giant cell arteritis (GCA) may present as proximal aortic pathology requiring surgical intervention. We present our experience with surgical management of GCA in patients presenting with proximal aortic disease.

Methods

From January 1993 to May 2020, 184 adult patients were diagnosed with GCA on histopathology after undergoing cardiac surgery. Survival was estimated with Kaplan-Meier method. Reoperation rates were estimated with cumulative incidence accounting for competing risks of death.

Results

The most common indication for surgery was ascending aortic aneurysm (n = 179, 97.3%). Stroke occurred in 6 (3.3%), pneumonia in 8 (4.4%), and dialysis in 3 (1.6%) patients. Multivariable analysis found advanced age (hazard ratio [HR], 1.054; 95% confidence interval [CI], 1.026-1.082, P < .001), recent heart failure (HR, 1.890; 95% CI, 1.016-3.516, P = .04), peripheral vascular disease (HR, 2.229; 95% CI, 1.458-3.624, P < .001), and cerebrovascular disease (HR, 1.762; 95% CI, 1.035-3.000, P = .03) as predictors of late mortality. Median follow-up was 13.7 years, and 30-day mortality was 1.5%. Nineteen patients underwent 24 aortic reinterventions including aortic arch reconstruction (n = 4), descending thoracic aorta aneurysm repair (n = 8), thoracoabdominal aortic aneurysm repair (n = 11), and pseudoaneurysm repair (n = 1). Rate of reintervention on the aorta was 3.9% (95% CI, 1.9%-8.1%), 7.1% (95% CI, 4.1%-12.3%), 12.8% (95% CI, 8.3%-19.6%), and 12.8% (95% CI, 8.3%-19.6%) at 1, 5, 10, and 15 years, respectively.

Conclusions

Surgery in patients with GCA can be performed with acceptable early and late outcomes. Advancing age, heart failure, peripheral vascular disease, and cerebrovascular disease are risk factors for worse survival. Postoperative surveillance is important as need for aortic reintervention is not uncommon.

目的：巨细胞动脉炎（GCA）可能表现为主动脉近端病变，需要手术干预。我们介绍了我们在主动脉近端病变患者的GCA手术治疗方面的经验。方法：1993年1月至2020年5月，对184例接受心脏手术后经组织病理学诊断为GCA的成人患者进行分析。用Kaplan-Meier法估计生存率。再手术率是用考虑竞争死亡风险的累积发生率估计的。结果：最常见的手术指征是升主动脉瘤（n = 179，占97.3%）。中风6例（3.3%），肺炎8例（4.4%），透析3例（1.6%）。多变量分析发现高龄(风险比[HR]， 1.054；95%可信区间[CI]， 1.026-1.082, P = 0.04)，外周血管疾病(HR, 2.229；95% CI, 1.458-3.624, P = .03)作为晚期死亡率的预测因子。中位随访时间为13.7年，30天死亡率为1.5%。19例患者接受了24次主动脉再干预，包括主动脉弓重建（n = 4）、胸降主动脉动脉瘤修复（n = 8）、胸腹主动脉瘤修复（n = 11）和假性动脉瘤修复（n = 1）。在1、5、10和15年，主动脉再干预率分别为3.9% （95% CI, 1.9%-8.1%）、7.1% （95% CI, 4.1%-12.3%）、12.8% （95% CI, 8.3%-19.6%）和12.8% （95% CI, 8.3%-19.6%）。结论：GCA患者的手术治疗可获得可接受的早期和晚期预后。高龄、心力衰竭、外周血管疾病和脑血管疾病是降低生存率的危险因素。术后监测是重要的，因为需要主动脉再介入治疗并不罕见。

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引用次数: 0

Combined simulation and ex vivo assessment of free-edge length in bicuspidization repair for congenital aortic valve disease 先天性主动脉瓣疾病双尖修复术中自由边缘长度的模拟与离体联合评估。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.008

Perry S. Choi MD , Amit Sharir BS , Yoshikazu Ono MD , Masafumi Shibata MD , Alexander D. Kaiser PhD , Yellappa Palagani PhD , Alison L. Marsden PhD , Michael R. Ma MD

Objective

The study objective was to investigate the effect of free-edge length on valve performance in bicuspidization repair of congenitally diseased aortic valves.

Methods

In addition to a constructed unicuspid aortic valve disease model, 3 representative groups—free-edge length to aortic diameter ratio 1.2, 1.57, and 1.8—were replicated in explanted porcine aortic roots (n = 3) by adjusting native free-edge length with bovine pericardium. Each group was run on a validated ex vivo univentricular system under physiological parameters for 20 cycles. All groups were tested within the same aortic root to minimize inter-root differences. Outcomes included transvalvular gradient, regurgitation fraction, and orifice area. Linear mixed effects model and pairwise comparisons were used to compare outcomes across groups.

Results

The diseased control group had a mean transvalvular gradient of 28.3 ± 5.5 mm Hg, regurgitation fraction of 29.6% ± 8.0%, and orifice area of 1.03 ± 0.15 cm². In ex vivo analysis, all repair groups had improved regurgitation and transvalvular gradient compared with the diseased control group (P < .001). Free-edge length to aortic diameter of 1.8 had the highest amount of regurgitation among the repair groups (P < .001) and 1.57 the least (P < .001). Free-edge length to aortic diameter of 1.57 also exhibited the lowest mean gradient (P < .001) and the largest orifice area (P < .001).

Conclusions

Free-edge length to aortic diameter ratio significantly impacts valve function in bicuspidization repair of congenitally diseased aortic valves. As the ratio departs from 1.57 in either direction, effective orifice area decreases and both transvalvular gradient and regurgitation fraction increase.

目的：探讨先天性病变主动脉瓣双尖置换术中自由瓣缘长度对瓣膜功能的影响。方法：在构建单尖瓣主动脉瓣疾病模型的基础上，利用牛心包调整原体自由缘长度，在离体猪主动脉根（n = 3）上复制自由缘长度与主动脉直径之比分别为1.2、1.57和1.8的3个代表性组。各组在经验证的体外单室系统生理参数下运行20个周期。所有组均在同一主动脉根内进行测试，以尽量减少根间差异。结果包括经瓣梯度、反流分数和孔口面积。采用线性混合效应模型和两两比较比较各组间的结果。结果：病变对照组经瓣梯度平均28.3±5.5 mm Hg，反流分数29.6%±8.0%，瓣口面积1.03±0.15 cm2。在离体分析中，与患病对照组相比，所有修复组的反流和跨瓣梯度均有改善（P P P P P P P）。结论：自由瓣缘长度与主动脉直径之比在先天性病变主动脉瓣双尖瓣修复中显著影响瓣膜功能。当该比值在两个方向上均大于1.57时，有效孔口面积减小，跨瓣梯度和反流分数均增大。

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引用次数: 0

Surgery versus surveillance for ascending aortic aneurysms in elderly patients 老年患者升主动脉瘤的手术与监测。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.08.021

Veronica F. Chan BSc , Ming Hao Guo MD, MSc , Thais Coutinho MD , Aryan Ahmadvand BSc , Mahdi Zeghal BSc , Adam Mussani BSc , Talal Al-Atassi MD, MPH , Roy Masters MD , David Glineur MD, PhD , Munir Boodhwani MD, MSc

Background

Whether elderly patients with aortic root or ascending aortic aneurysm (ATAA) would benefit from the new surgical size threshold of 5.0 cm is unknown. This study aimed to evaluate the natural history of ATAA in elderly patients and to compare long-term outcomes of those who underwent initial surveillance versus surgery.

Methods

Patients age ≥75 years with an ATAA ≥40 mm were categorized into 2 groups: initial surgery and initial surveillance. The primary outcome was all-cause mortality; Kaplan-Meier curves were plotted for survival. A multivariable Cox proportional hazard regression model was used to identify independent predictors of long-term mortality.

Results

The study series comprised 300 patients, including 58 who underwent initial surgery and 242 who received surveillance between July 2010 and September 2022. In the surveillance cohort, the mean aneurysm growth rate was 0.10 cm/year. Comparing surveillance to surgery, at 8 years there was no difference in survival (mean, 77.8 ± 3.4% vs 71.8 ± 9.6%; P = .65). For 116 patients with an initial aneurysm diameter ≥5.0 cm, there was no difference in survival between the 2 groups at 8 years (76.5 ± 7.0% vs 68.4 ± 11.3%; P = .20). Larger body surface area (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.09-1.90; P = .01) and history of smoking (HR, 2.25; 95% CI, 1.27-3.98; P = .01) were identified as predictors of long-term mortality.

Conclusions

In our series of elderly patients with ATAA, there was no difference in 8-year survival between initial surveillance and surgical management, with a high competing risk of nonaortic mortality. Surveillance may be a reasonable alternative to surgery for selected older adults with ATAA <5.5 cm.

背景：老年主动脉根或升主动脉瘤（ATAA）患者是否会从5.0 cm的新手术尺寸阈值中获益尚不清楚。本研究旨在评估老年患者ATAA的自然病史，并比较接受初始监测和手术治疗的患者的长期预后。方法：年龄≥75岁，ATAA≥40 mm的患者分为初始手术组和初始监测组。主要结局是全因死亡率；绘制Kaplan-Meier曲线表示生存率。采用多变量Cox比例风险回归模型确定长期死亡率的独立预测因子。结果：该研究系列包括300例患者，其中58例接受了首次手术，242例在2010年7月至2022年9月期间接受了监测。在监测队列中，平均动脉瘤生长速度为0.10 cm/年。与监测与手术相比，8年生存率无差异(平均77.8±3.4% vs 71.8±9.6%；p = .65)。对于116例初始动脉瘤直径≥5.0 cm的患者，两组8年生存率无差异(76.5±7.0% vs 68.4±11.3%；p = .20)。较大的体表面积(风险比[HR]， 1.44；95%置信区间[CI]， 1.09-1.90；P = 0.01)和吸烟史(HR, 2.25；95% ci, 1.27-3.98；P = 0.01)被确定为长期死亡率的预测因子。结论：在我们的老年ATAA患者系列中，初始监测和手术治疗之间的8年生存率没有差异，但非主动脉死亡的竞争风险很高。对于某些老年ATAA患者，监测可能是手术之外的合理选择

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引用次数: 0