JTCVS open最新文献_第9页

Commentator Discussion: Out of the ice age: Preservation of cardiac allografts with a reusable 10 °C cooler 解说员讨论：走出冰河时代：用可重复使用的10°C冷却器保存同种异体心脏移植物。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.013

引用次数: 0

Significant reduction in blood product usage, same early outcomes: Blood conservation in infants undergoing open heart surgery 血液制品使用显著减少，早期结果相同：接受心脏直视手术的婴儿血液保存。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.10.006

Lyubomyr Bohuta MD, PhD , Titus Chan MD, MS, MPP , Kevin Charette CCP , Gregory Latham MD , Christina L. Greene MD , David Mauchley MD , Andrew Koth MD , D. Michael McMullan MD

Objective

To evaluate the effect of a blood conservation program on trends in use of donor blood products and early clinical outcomes in infants undergoing open heart surgery.

Methods

Four hundred nine patients younger than age 1 year undergoing open-heart surgery between October 1, 2020, and June 30, 2023, were reviewed. The study period was divided into 4 eras with the first era as a before blood conservation baseline using traditional blood management. The following 3 eras comprised incremental implementation and evolution of blood conservation strategies. The total volume of blood products transfused for each surgical hospitalization was calculated and indexed to body weight at time of surgery.

Results

There was no significant difference in age at surgery, body weight, distribution of The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categories, and in postoperative length of mechanical ventilation, intensive care unit or hospital length of stay, or postoperative mortality (P > .05 for all) across the 4 eras. Median total volume of blood products administered during hospitalization decreased from 128 mL/kg (range, 92-220 mL/kg) during the baseline period to 21 mL/kg (range, 6-44 mL/kg) during the last era (P < .01). Multivariate analysis demonstrated that later eras were associated with decreased odds of experiencing exposure to blood products during hospitalization.

Conclusions

Blood conservation is associated with significant reduction in usage of blood products during open heart surgery in infants with no significant effect on early outcomes. This trend is observed across all categories of surgical complexity. Additional studies are needed to prove consistency and to determine the longer-term clinical impact of this strategy.

目的：评估血液保护计划对接受心脏直视手术的婴儿供体血液制品使用趋势和早期临床结果的影响。方法：对2020年10月1日至2023年6月30日期间接受心脏直视手术的490例年龄小于1岁的患者进行回顾性分析。研究期分为4个时期，第一个时期为采用传统血液管理前的血液保护基线。接下来的3个时代包括血液保护策略的逐步实施和演变。计算每次手术住院的输血总量，并以手术时的体重为指标。结果：手术年龄、体重、胸外科学会-欧洲心胸外科协会分类分布、术后机械通气时间、重症监护病房或住院时间、术后死亡率在4个时代均无显著差异（P < 0.05）。住院期间使用的血液制品中位数总容量从基线期的128 mL/kg（范围，92-220 mL/kg）降至上一个时期的21 mL/kg（范围，6-44 mL/kg） (P结论：血液保存与婴儿心脏手术期间血液制品使用量的显著减少有关，但对早期结局没有显著影响。这一趋势在所有类型的复杂手术中都可以观察到。需要进一步的研究来证明一致性并确定该策略的长期临床影响。

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引用次数: 0

Clinicopathologic and genomic features associated with brain metastasis after resection of lung adenocarcinoma 肺腺癌切除术后脑转移的临床病理和基因组特征。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.030

Elizabeth G. Dunne MD , Cameron N. Fick MD , Brooke Mastrogiacomo MS , Kay See Tan PhD , Nicolas Toumbacaris MSPH , Stijn Vanstraelen MD , Gaetano Rocco MD , Jaime E. Chaft MD , Puneeth Iyengar MD , Daniel Gomez MD , Prasad S. Adusumilli MD , Bernard J. Park MD , James M. Isbell MD , Matthew J. Bott MD , Smita Sihag MD , Daniela Molena MD , James Huang MD , David R. Jones MD

Objective

To identify clinicopathologic and genomic features associated with brain metastasis after resection of lung adenocarcinoma (LUAD) and to evaluate survival after brain metastasis.

Methods

Patients who underwent complete resection of stage I-IIIA LUAD between 2011 and 2020 were included. A subset of patients had broad-based panel next-generation sequencing performed on their tumors. Fine-Gray models for the development of brain metastasis were constructed, with death without brain metastasis as a competing risk.

Results

A total of 2660 patients were included. The median duration of follow-up was 71 months (95% confidence interval [CI], 69-73 months). The cumulative incidence of brain metastasis at 10 years was 9.8%. Among patients who developed a brain metastasis, the median time from surgery to brain metastasis was 21 months (interquartile range, 10-42 months). Higher maximum standardized uptake value of the primary tumor, neoadjuvant therapy, lymphovascular invasion, and stage III disease were associated with the development of brain metastasis. Among patients who underwent next-generation sequencing, a multivariable analysis identified neoadjuvant therapy, pathologic stage, and TP53 mutations as associated with development of brain metastasis. The median survival after brain metastasis was 18 months (95% CI, 13-24 months). Better performance status, lack of extracranial metastasis, stereotactic radiosurgery, and targeted therapy were associated with better survival after brain metastasis.

Conclusions

Brain metastasis is common after complete resection of LUAD and often occurs within 2 years. Markers of aggressive tumor biology, including higher maximum standardized uptake value, lymphovascular invasion, and TP53 mutations, and neoadjuvant therapy are associated with brain metastasis.

目的：探讨肺腺癌（LUAD）术后脑转移的临床病理和基因组特征，并评价脑转移后的生存率。方法：纳入2011年至2020年间全部切除I-IIIA期LUAD的患者。一部分患者对其肿瘤进行了广泛的新一代面板测序。构建了脑转移发展的细灰色模型，其中无脑转移的死亡是一种竞争风险。结果：共纳入2660例患者。中位随访时间为71个月（95%可信区间[CI]， 69-73个月）。10年脑转移的累积发生率为9.8%。在发生脑转移的患者中，从手术到脑转移的中位时间为21个月（四分位数范围为10-42个月）。原发肿瘤、新辅助治疗、淋巴血管侵袭和III期疾病的最大标准化摄取值较高与脑转移的发生有关。在接受新一代测序的患者中，一项多变量分析确定了新辅助治疗、病理分期和TP53突变与脑转移的发生有关。脑转移后的中位生存期为18个月（95% CI， 13-24个月）。较好的运动状态、无颅外转移、立体定向放射手术和靶向治疗与脑转移后较好的生存率相关。结论：LUAD完全切除后脑转移较为常见，常在2年内发生。侵袭性肿瘤生物学标志物，包括较高的最大标准化摄取值、淋巴血管侵袭、TP53突变和新辅助治疗与脑转移有关。

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引用次数: 0

Five-year comparison of clinical and echocardiographic outcomes of pure aortic stenosis with pure aortic regurgitation or mixed aortic valve disease in the COMMENCE trial 纯主动脉瓣狭窄与纯主动脉瓣反流或混合性主动脉瓣疾病的5年临床和超声心动图结果比较

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.08.020

Vinod H. Thourani MD , John D. Puskas MD , Bartley Griffith MD , Lars G. Svensson MD, PhD , Philippe Pibarot DVM, PhD , Michael A. Borger MD, PhD , David Heimansohn MD , Thomas Beaver MD, MPH , Eugene H. Blackstone MD , Anna Liza M. Antonio DrPH , Joseph E. Bavaria MD, MPH , COMMENCE Trial Investigators

Objective

To compare outcomes of aortic valve replacement (AVR) in patients with pure aortic stenosis (Pure AS) and those with pure aortic regurgitation (Pure AR) or mixed AS and AR (MAVD) in the COMMENCE trial.

Methods

Of 689 patients who underwent AVR in the COMMENCE trial, patients with moderate or severe AR with or without AS (Pure AR + MAVD; n = 135) or Pure AS (n = 323) were included. Inverse probability of treatment weighting Kaplan-Meier survival curves were used for time-to-event endpoints, and longitudinal changes in hemodynamics were evaluated using mixed-effects models. Echocardiographic outcomes were assessed by an echo core laboratory and clinical outcomes adjudicated by a clinical events committee. The mean duration of follow-up was 5.3 ± 2.2 years.

Results

At 5 years, adjusted safety endpoints were not statistically different between groups; no structural valve deterioration (SVD) event occurred in either group. After adjustment, the Pure AR + MAVD group had a greater change in body surface area–corrected left ventricular (LV) mass reduction (P = .03) compared to the Pure AS patients. Those patients with a baseline LV ejection fraction (LVEF) >55% continued to demonstrate preserved contractility compared to patients with an LVEF ≤55% at baseline (P < .0001). No significant difference in mean gradient (P = .07) or effective orifice area (P = .96) at 5 years was evident between the groups.

Conclusions

Patients with Pure AR + MAVD demonstrated similar clinical safety and freedom from SVD at 5 years compared to those with Pure AS. There was a significant difference in LV reverse remodeling in the Pure AR + MAVD group compared to the Pure AS group at 5 years. These favorable outcomes in patients with AR may reinforce the need for treatment before irreversible changes occur.

目的：比较单纯主动脉瓣狭窄（pure AS）与单纯主动脉瓣返流（pure AR）或混合型主动脉瓣返流（MAVD）患者主动脉瓣置换术（AVR）的疗效。方法：在开始试验中接受AVR的689例患者中，中度或重度AR伴或不伴AS的患者(纯AR + MAVD；n = 135)或Pure AS （n = 323）。使用治疗加权的逆概率Kaplan-Meier生存曲线作为时间到事件的终点，使用混合效应模型评估血流动力学的纵向变化。超声心动图结果由超声核心实验室评估，临床结果由临床事件委员会裁决。平均随访时间5.3±2.2年。结果：5年时，两组间调整后的安全终点无统计学差异；两组均未发生结构性瓣膜恶化（SVD）事件。调整后，与Pure AS患者相比，Pure AR + MAVD组体表面积校正左室（LV）质量缩小变化更大（P = .03）。与基线时左室射血分数(LVEF)≤55% （P = 0.07）或有效孔口面积（P = 0.96）的患者相比，基线时左室射血分数(LVEF)≤55%的患者在5年时继续表现出保留的收缩能力，这在两组之间是明显的。结论：与纯AS患者相比，纯AR + MAVD患者在5年的临床安全性和SVD自由度相似。5年时，纯AR + MAVD组与纯AS组相比，左室逆转重构有显著差异。AR患者的这些有利结果可能会加强在不可逆变化发生之前进行治疗的必要性。

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引用次数: 0

Intraoperative right ventricular end-systolic pressure–volume loop analysis in patients undergoing cardiac surgery: A proof-of-concept methodology 心脏手术患者术中右心室收缩末期压力-容量环分析：概念验证方法学。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.020

Vahid Kiarad MD, MPH , Feroze Mahmood MD, FASE , Mona Hedayat MD , Rayaan Yunus MPH , Alina Nicoara MD , David Liu MD , Louis Chu MD , Vankatachalam Senthilnathan MD , Masashi Kai MD , Kamal Khabbaz MD

Background

Perioperative right ventricular (RV) dysfunction is associated with increased morbidity and mortality in cardiac surgery patients. This study aimed to demonstrate proof of concept in generating intraoperative RV pressure–volume (PV) loops and conducting an end-systolic PV relationship (ESPVR) analysis using data obtained from routinely used intraoperative monitors.

Methods

Adult patients undergoing cardiac surgery with the placement of a pulmonary artery catheter (PAC) between May 2023 and March 2024 were included prospectively. The PV loops were generated using 3-dimensional echocardiographic RV volume data and continuous RV pressure data obtained from a PAC. The volume–time and pressure–time curves were digitized using the semiautomatic WebPlotDigitizer program and synchronized to reconstruct an RV PV loop and analyze ESPVR using the previously validated single-beat method.

Results

Intraoperative RV PV loops were generated for 25 patients, including 17 patients with preserved RV systolic function (group 1) and 8 patients with reduced systolic function (group 2). Mean E_es, E_a, and E_es/E_a ratio were 0.63 ± 0.25 mm Hg/mL, 0.60 ± 0.23 mm Hg/mL, and 1.0 8 ± 0.31 mm Hg/mL, respectively, by the P_max method and 0.56 ± 0.32 mm Hg/mL, 0.60 ± 0.23 mm Hg/mL, and 0.91 ± 0.21 mm Hg/mL, respectively, by the V₀ method. Group 1 had a significantly higher E_es compared to group 2 regardless of the calculation method and a larger E_es/E_a ratio calculated by the V₀ method.

Conclusions

It is clinically feasible to derive RV PV loops from routine hemodynamic and echocardiographic data. With further validation and technological support, this can be a potential real-time intraoperative RV function monitoring tool.

背景：围手术期右心室功能障碍与心脏手术患者发病率和死亡率增加有关。本研究旨在验证术中心室压力-容积（PV）循环产生的概念，并利用术中常规使用的监护仪获得的数据进行收缩期末期PV关系（ESPVR）分析。方法：前瞻性纳入2023年5月至2024年3月期间接受心脏手术并放置肺动脉导管（PAC）的成年患者。利用三维超声心动图右心室容积数据和PAC获得的连续右心室压力数据生成PV环路。使用半自动WebPlotDigitizer程序对容积时间和压力时间曲线进行数字化，并同步重建右心室PV环路，并使用先前验证的单拍方法分析ESPVR。结果:术中房车PV循环生成25例,其中17患者保存房车收缩功能(组1)收缩功能下降患者和8(组2)。意思是ee, Ea和ee / Ea比率分别为0.63±0.25 mm Hg / mL, 0.60±0.23 mm Hg /毫升,8和1.0±0.31毫米汞柱/ mL,分别由Pmax方法和0.56±0.32 mm Hg /毫升,0.60±0.23 mm Hg /毫升,和0.91±0.21毫米汞柱/ mL,分别由V0方法。无论采用何种计算方法，1组的Ees均显著高于2组，且采用V0法计算的Ees/Ea比值较大。结论：从常规血流动力学和超声心动图数据推断右室PV袢在临床上是可行的。在进一步的验证和技术支持下，这可能成为一种潜在的术中心室功能实时监测工具。

{"title":"Intraoperative right ventricular end-systolic pressure–volume loop analysis in patients undergoing cardiac surgery: A proof-of-concept methodology","authors":"Vahid Kiarad MD, MPH , Feroze Mahmood MD, FASE , Mona Hedayat MD , Rayaan Yunus MPH , Alina Nicoara MD , David Liu MD , Louis Chu MD , Vankatachalam Senthilnathan MD , Masashi Kai MD , Kamal Khabbaz MD","doi":"10.1016/j.xjon.2024.09.020","DOIUrl":"10.1016/j.xjon.2024.09.020","url":null,"abstract":"<div><h3>Background</h3><div>Perioperative right ventricular (RV) dysfunction is associated with increased morbidity and mortality in cardiac surgery patients. This study aimed to demonstrate proof of concept in generating intraoperative RV pressure–volume (PV) loops and conducting an end-systolic PV relationship (ESPVR) analysis using data obtained from routinely used intraoperative monitors.</div></div><div><h3>Methods</h3><div>Adult patients undergoing cardiac surgery with the placement of a pulmonary artery catheter (PAC) between May 2023 and March 2024 were included prospectively. The PV loops were generated using 3-dimensional echocardiographic RV volume data and continuous RV pressure data obtained from a PAC. The volume–time and pressure–time curves were digitized using the semiautomatic WebPlotDigitizer program and synchronized to reconstruct an RV PV loop and analyze ESPVR using the previously validated single-beat method.</div></div><div><h3>Results</h3><div>Intraoperative RV PV loops were generated for 25 patients, including 17 patients with preserved RV systolic function (group 1) and 8 patients with reduced systolic function (group 2). Mean E<sub>es</sub>, E<sub>a</sub>, and E<sub>es</sub>/E<sub>a</sub> ratio were 0.63 ± 0.25 mm Hg/mL, 0.60 ± 0.23 mm Hg/mL, and 1.0 8 ± 0.31 mm Hg/mL, respectively, by the P<sub>max</sub> method and 0.56 ± 0.32 mm Hg/mL, 0.60 ± 0.23 mm Hg/mL, and 0.91 ± 0.21 mm Hg/mL, respectively, by the V<sub>0</sub> method. Group 1 had a significantly higher E<sub>es</sub> compared to group 2 regardless of the calculation method and a larger E<sub>es</sub>/E<sub>a</sub> ratio calculated by the V<sub>0</sub> method.</div></div><div><h3>Conclusions</h3><div>It is clinically feasible to derive RV PV loops from routine hemodynamic and echocardiographic data. With further validation and technological support, this can be a potential real-time intraoperative RV function monitoring tool.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"22 ","pages":"Pages 225-234"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142960074","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

Is concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective? 接受机器人二尖瓣修复术的患者同时进行三尖瓣修复安全有效吗？

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.021

Phillip G. Rowse MD , Yazan AlJamal MBBS , Richard C. Daly MD , Austin Todd MS , Arman Arghami MD, MPH , Juan A. Crestanello MD , Joseph A. Dearani MD

Objectives

Robotic-assisted mitral valve repair (MVr) is a well-established procedure for management of degenerative mitral valve disease. Limited data regarding concomitant robotic-assisted tricuspid valve repair (TVr) is available. This review investigates prevalence and outcomes of concomitant robotic-assisted mitral and tricuspid valve repair.

Methods

From 2014 to 2022, 839 patients underwent robotic-assisted MVr, including 76 patients with moderate or greater tricuspid regurgitation and/or tricuspid annular dilatation ≥40 mm. Among the 76 patients, 19 (25%) underwent isolated MVr and 57 (75%) had concomitant mitral and tricuspid valve repair. Outcome data between the 2 groups were analyzed.

Results

In the MVr/TVr group, tricuspid regurgitation grades were mild in 4 (7%) patients, moderate in 44 (77%) and severe in 9 (15.7%). Significant tricuspid annular dilatation ≥40 mm was present in all patients. In the isolated MVr group, 3 (15.7%) patients had mild tricuspid regurgitation and 16 (84.2%) had moderate tricuspid regurgitation with significant tricuspid annular dilatation present in only 6 patients. Cardiopulmonary bypass and crossclamp time were 130.6 and 91 minutes versus 85 and 55.4 minutes for robotic MVr/TVr group versus MVr group, respectively (P < .05). The intensive care unit and hospital length of stay were similar: 27.7 versus 27.7 hours and 4.4 versus 4.2 days for MVr/TVr versus MVr (P = .24), respectively. There were no perioperative deaths or heart block in either group. Survival and freedom from reoperation with median follow-up of 16 and 46 months for MVr/TVr and MVr groups, respectively were 100%.

Conclusions

Concomitant robotic-assisted tricuspid valve repair for functional regurgitation can be safely and effectively performed at the time of mitral valve repair with excellent short-term morbidity and mortality results.

目的：机器人辅助二尖瓣修复（MVr）是一种成熟的治疗退行性二尖瓣疾病的方法。关于伴随机器人辅助三尖瓣修复（TVr）的数据有限。本文综述了机器人辅助二尖瓣和三尖瓣修复的患病率和结果。方法：2014年至2022年，839例患者接受了机器人辅助MVr，其中76例患者患有中度或重度三尖瓣反流和/或三尖瓣环扩张≥40 mm。在76例患者中，19例（25%）接受了孤立的MVr， 57例（75%）同时进行了二尖瓣和三尖瓣修复。分析两组预后数据。结果：在MVr/TVr组中，轻度4例（7%），中度44例（77%），重度9例（15.7%）。所有患者均存在明显的三尖瓣环扩张≥40 mm。在孤立MVr组中，3例（15.7%）患者出现轻度三尖瓣反流，16例（84.2%）患者出现中度三尖瓣反流，仅有6例患者出现明显的三尖瓣环扩张。机器人MVr/TVr组和MVr组的体外循环时间分别为130.6分钟和91分钟，而机器人MVr/TVr组分别为85分钟和55.4分钟（P = 0.24）。两组患者均无围手术期死亡或心脏传导阻滞。MVr/TVr组和MVr组的中位随访时间分别为16个月和46个月，生存率和再手术自由度均为100%。结论：在二尖瓣修复术中，机器人辅助三尖瓣修复术可安全有效地治疗功能性返流，短期发病率和死亡率均较好。

{"title":"Is concomitant tricuspid valve repair in patients undergoing robotic mitral valve repair safe and effective?","authors":"Phillip G. Rowse MD , Yazan AlJamal MBBS , Richard C. Daly MD , Austin Todd MS , Arman Arghami MD, MPH , Juan A. Crestanello MD , Joseph A. Dearani MD","doi":"10.1016/j.xjon.2024.09.021","DOIUrl":"10.1016/j.xjon.2024.09.021","url":null,"abstract":"<div><h3>Objectives</h3><div>Robotic-assisted mitral valve repair (MVr) is a well-established procedure for management of degenerative mitral valve disease. Limited data regarding concomitant robotic-assisted tricuspid valve repair (TVr) is available. This review investigates prevalence and outcomes of concomitant robotic-assisted mitral and tricuspid valve repair.</div></div><div><h3>Methods</h3><div>From 2014 to 2022, 839 patients underwent robotic-assisted MVr, including 76 patients with moderate or greater tricuspid regurgitation and/or tricuspid annular dilatation ≥40 mm. Among the 76 patients, 19 (25%) underwent isolated MVr and 57 (75%) had concomitant mitral and tricuspid valve repair. Outcome data between the 2 groups were analyzed.</div></div><div><h3>Results</h3><div>In the MVr/TVr group, tricuspid regurgitation grades were mild in 4 (7%) patients, moderate in 44 (77%) and severe in 9 (15.7%). Significant tricuspid annular dilatation ≥40 mm was present in all patients. In the isolated MVr group, 3 (15.7%) patients had mild tricuspid regurgitation and 16 (84.2%) had moderate tricuspid regurgitation with significant tricuspid annular dilatation present in only 6 patients. Cardiopulmonary bypass and crossclamp time were 130.6 and 91 minutes versus 85 and 55.4 minutes for robotic MVr/TVr group versus MVr group, respectively (<em>P</em> < .05). The intensive care unit and hospital length of stay were similar: 27.7 versus 27.7 hours and 4.4 versus 4.2 days for MVr/TVr versus MVr (<em>P</em> = .24), respectively. There were no perioperative deaths or heart block in either group. Survival and freedom from reoperation with median follow-up of 16 and 46 months for MVr/TVr and MVr groups, respectively were 100%.</div></div><div><h3>Conclusions</h3><div>Concomitant robotic-assisted tricuspid valve repair for functional regurgitation can be safely and effectively performed at the time of mitral valve repair with excellent short-term morbidity and mortality results.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"22 ","pages":"Pages 214-221"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704553/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142960075","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

Association between the proportionality of functional mitral regurgitation and survival after mitral valve operation 二尖瓣手术后功能性二尖瓣返流比例与生存的关系。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.06.006

Makoto Mori MD, PhD , Christina Waldron BS , Sigurdur Ragnarsson MD , Soh Hosoba MD, PhD , Mina Zaky MD , Dustin Lieu MD , Markus Krane MD , Arnar Geirsson MD

Objective

The concept of proportionate and disproportionate functional mitral regurgitation suggests that transcatheter edge-to-edge mitral repair may benefit patients with a smaller left ventricle relative to a higher regurgitant burden. The clinical relevance of proportionality remains unknown in mitral operations for ischemic mitral regurgitation. We aimed to characterize the association between mitral regurgitation proportionality and outcomes after mitral valve operations.

Methods

By using the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial, we first identified the inflection point at which the risk of 2-year mortality changed along the spectrum of the mitral regurgitation proportionality (defined as effective regurgitant orifice area/left ventricular end-diastolic volume index) using a splined multivariable Cox proportional hazards model. Patients were dichotomized by the mitral regurgitation proportionality value. The Cox model evaluated the hazard of 2-year all-cause mortality between proportionate and disproportionate mitral regurgitation.

Results

Among the 240 patients, the median age was 69 years (interquartile range, 62-75), and 38% (n = 90) were women. Patients with effective regurgitant orifice/left ventricular end-diastolic volume index proportion greater than 0.40 (more disproportionate mitral regurgitation) had a higher hazard of death compared with those with more proportionate mitral regurgitation. The 90-day and 1-year mortality were higher in patients with disproportionate mitral regurgitation (13% vs 6.2% for 90 days and 19% vs 12% for 1 year). In a multivariable Cox model, the disproportionate mitral regurgitation group had a statistically significantly higher hazard of death compared with the proportionate mitral regurgitation group (hazard ratio, 2.15, 95% CI, 1.16-3.98, P = .015).

Conclusions

The clinical relevance of the proportionality of functional mitral regurgitation proposed in the transcatheter edge-to-edge mitral repair population may not generalize to surgical patient populations.

目的：比例和不成比例功能二尖瓣反流的概念表明，经导管二尖瓣边缘到边缘修复可能有利于左心室较小而反流负担较高的患者。比例在二尖瓣手术治疗缺血性二尖瓣反流中的临床意义尚不清楚。我们的目的是描述二尖瓣手术后二尖瓣返流比例与结果之间的关系。方法：通过心胸外科试验网络的严重缺血性二尖瓣反流试验，我们首先使用样条多变量Cox比例风险模型确定了2年死亡率风险沿二尖瓣反流比例（定义为有效反流口面积/左室舒张末期容积指数）谱变化的拐点。根据二尖瓣反流比例值对患者进行分类。Cox模型评估了比例二尖瓣反流和不成比例二尖瓣反流之间2年全因死亡率的风险。结果：240例患者中位年龄为69岁（四分位数范围为62-75岁），女性占38% （n = 90）。有效反流口/左心室舒张末期容积指数比例大于0.40（更不成比例的二尖瓣反流）的患者比不成比例的二尖瓣反流的患者死亡风险更高。不成比例二尖瓣返流患者90天和1年死亡率较高（90天13% vs 6.2%， 1年19% vs 12%）。在多变量Cox模型中，与比例二尖瓣反流组相比，比例二尖瓣反流组的死亡风险具有统计学意义（风险比，2.15,95% CI, 1.16-3.98, P = 0.015）。结论：在经导管边缘到边缘二尖瓣修复人群中提出的功能性二尖瓣反流比例的临床相关性可能不会推广到外科患者群体。

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引用次数: 0

Rapid-recovery protocol for minimally invasive mitral valve repair 微创二尖瓣修复快速恢复方案。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.08.006

Amy Brown MD, MPH , Ali Fatehi Hassanabad MD , Jolene Moen RN , Karen Wiens RN , Alexander J. Gregory MD , Ken Kuljit S. Parhar MD , Corey Adams MD , William D.T. Kent MD

Background

Minimally invasive mitral valve repair (MIMVR), often performed within specialized care pathways, has been shown to reduce hospital length of stay and improve patient recovery. The relative value of rapid-recovery protocols as a component of care pathways, including enhanced recovery programs (ERPs), has not been well described. This study compared clinical outcomes following implementation of a new, comprehensive rapid-recovery protocol within a previously established, mature ERP for patients undergoing MIMVR.

Methods

The rapid-recovery protocol was developed and implemented by a multidisciplinary team to further optimize patient recovery within an existing ERP. The protocol was applied to 75 consecutive patients undergoing MIMVR between September 2022 and December 2023. Outcomes were compared retrospectively to 75 ERP control patients who did not receive the rapid-recovery protocol but experienced the ERP. The primary outcome was a composite of discharge from the intensive care unit (ICU) by postoperative day (POD) 1, discharge to home by POD 4, and no all-cause hospital readmission by 30 days.

Results

Baseline characteristics were similar in the 2 groups. Patients in the rapid-recovery group achieved the primary composite outcome significantly more often compared to the control group (60% vs 40%, respectively). There was no between-group difference in postoperative complications. Multivariable logistic regression showed that age ≤60 years was significantly associated with rapid-recovery protocol success. Clinical barriers to achieving individual components of the primary outcome were described.

Conclusions

A rapid-recovery protocol for MIMVR was associated with early ICU and hospital discharge. These benefits were safely achieved without any increase in hospital readmission, morbidity, or mortality up to 30 days postoperatively.

背景：微创二尖瓣修复（MIMVR）通常在专业护理途径下进行，已被证明可以缩短住院时间并改善患者康复。快速恢复方案作为护理途径的一个组成部分的相对价值，包括增强恢复计划（erp），尚未得到很好的描述。本研究比较了在先前建立的成熟ERP中对MIMVR患者实施新的全面快速恢复方案后的临床结果。方法：快速恢复方案由一个多学科团队开发和实施，以进一步优化现有ERP的患者恢复。该方案在2022年9月至2023年12月期间连续应用于75名接受MIMVR的患者。回顾性比较75例ERP对照患者的结果，这些患者没有接受快速恢复方案，但经历了ERP。主要终点为术后第1天（POD）从重症监护病房（ICU）出院，第4天（POD）出院，30天无全因再入院。结果：两组患者的基线特征相似。与对照组相比，快速恢复组患者实现主要综合结局的频率明显更高（分别为60%和40%）。两组术后并发症发生率无明显差异。多变量logistic回归显示，年龄≤60岁与快速恢复方案的成功显著相关。描述了实现主要结果的各个组成部分的临床障碍。结论：快速恢复方案与早期ICU和出院有关。这些益处是安全实现的，术后30天未出现再入院、发病率或死亡率的增加。

{"title":"Rapid-recovery protocol for minimally invasive mitral valve repair","authors":"Amy Brown MD, MPH , Ali Fatehi Hassanabad MD , Jolene Moen RN , Karen Wiens RN , Alexander J. Gregory MD , Ken Kuljit S. Parhar MD , Corey Adams MD , William D.T. Kent MD","doi":"10.1016/j.xjon.2024.08.006","DOIUrl":"10.1016/j.xjon.2024.08.006","url":null,"abstract":"<div><h3>Background</h3><div>Minimally invasive mitral valve repair (MIMVR), often performed within specialized care pathways, has been shown to reduce hospital length of stay and improve patient recovery. The relative value of rapid-recovery protocols as a component of care pathways, including enhanced recovery programs (ERPs), has not been well described. This study compared clinical outcomes following implementation of a new, comprehensive rapid-recovery protocol within a previously established, mature ERP for patients undergoing MIMVR.</div></div><div><h3>Methods</h3><div>The rapid-recovery protocol was developed and implemented by a multidisciplinary team to further optimize patient recovery within an existing ERP. The protocol was applied to 75 consecutive patients undergoing MIMVR between September 2022 and December 2023. Outcomes were compared retrospectively to 75 ERP control patients who did not receive the rapid-recovery protocol but experienced the ERP. The primary outcome was a composite of discharge from the intensive care unit (ICU) by postoperative day (POD) 1, discharge to home by POD 4, and no all-cause hospital readmission by 30 days.</div></div><div><h3>Results</h3><div>Baseline characteristics were similar in the 2 groups. Patients in the rapid-recovery group achieved the primary composite outcome significantly more often compared to the control group (60% vs 40%, respectively). There was no between-group difference in postoperative complications. Multivariable logistic regression showed that age ≤60 years was significantly associated with rapid-recovery protocol success. Clinical barriers to achieving individual components of the primary outcome were described.</div></div><div><h3>Conclusions</h3><div>A rapid-recovery protocol for MIMVR was associated with early ICU and hospital discharge. These benefits were safely achieved without any increase in hospital readmission, morbidity, or mortality up to 30 days postoperatively.</div></div>","PeriodicalId":74032,"journal":{"name":"JTCVS open","volume":"22 ","pages":"Pages 49-60"},"PeriodicalIF":0.0,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11704579/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142959781","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

Predicting operative mortality in patients who undergo elective open thoracoabdominal aortic aneurysm repair 预测择期胸腹主动脉瘤开放性修复患者的手术死亡率。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.002

Kyle W. Blackburn BS , Susan Y. Green MPH , Allen Kuncheria BA , Meng Li PhD , Adel M. Hassan BA , Brittany Rhoades PhD , Scott A. Weldon MA , Subhasis Chatterjee MD , Marc R. Moon MD , Scott A. LeMaire MD , Joseph S. Coselli MD

Background

We have developed a model aimed at identifying preoperative predictors of operative mortality in patients who undergo elective, open thoracoabdominal aortic aneurysm (TAAA) repair. We converted this model into an intuitive nomogram to aid preoperative counseling.

Methods

We retrospectively analyzed data from 2884 elective, open TAAA repairs performed between 1986 and 2023 in a single practice. Using clinical and selected operative variables, we built 4 predictive models: multivariable logistic regression (MLR), random forest, support vector machine, and gradient boosting machine. Each model’s predictive effectiveness was evaluated with the C-statistic. Test C-statistics were computed using an 80:20 cross-validation scheme with 1000 iterations.

Results

Operative death occurred in 200 patients (6.9%). Test set C-statistics showed that the MLR model (median, 0.68; interquartile range [IQR], 0.65-0.71) outperformed the machine learning models (0.61 [IQR, 0.59-0.64] for random forest; 0.61 [IQR, 0.58-0.64] for support vector machine; 0.65 [IQR, 0.62-0.67] for gradient boosting machine). The final MLR model was based on 7 characteristics: increasing age (odds ratio [OR], 1.04/y; P < .001), cerebrovascular disease (OR, 1.54; P = .01), chronic kidney disease (OR, 1.53; P = .008), symptomatic aneurysm (OR, 1.42; P = .02), and Crawford extent I (OR, 0.66; P = .08), extent II (OR, 1.61; P = .01), and extent IV (OR, 0.41; P = .002). We converted this model into a nomogram.

Conclusions

Using institutional data, we evaluated several models to predict operative mortality in elective TAAA repair, using information available to surgeons preoperatively. We then converted the best predictive model, the MLR model, into an intuitive nomogram to aid patient counseling.

背景：我们建立了一个模型，旨在确定择期开放性胸腹主动脉瘤（TAAA）修复患者手术死亡率的术前预测因素。我们将这个模型转换成直观的nomogram来帮助术前咨询。方法：回顾性分析1986年至2023年间2884例选择性开放式TAAA修补术的资料。利用临床和选定的手术变量，我们建立了4种预测模型：多变量逻辑回归（MLR）、随机森林、支持向量机和梯度增强机。用c统计量评价各模型的预测有效性。测试c统计使用80:20的交叉验证方案计算，迭代1000次。结果：手术死亡200例（6.9%）。检验集c统计量显示，MLR模型(中位数，0.68；四分位数间距[IQR]， 0.65-0.71)优于机器学习模型(随机森林为0.61 [IQR, 0.59-0.64]；0.61 [IQR, 0.58-0.64]；0.65 [IQR, 0.62-0.67]为梯度增强机)。最终的MLR模型基于7个特征：年龄增加(优势比[OR]， 1.04/y；P P = 0.01)，慢性肾病(OR, 1.53；P = 0.008)，有症状的动脉瘤(OR, 1.42；P = .02)， Crawford程度I (OR, 0.66；P = .08)，程度II (OR, 1.61；P = 0.01)，程度IV (OR, 0.41；p = .002)。我们把这个模型转换成图形。结论：利用机构数据，我们评估了几种预测选择性TAAA修复手术死亡率的模型，使用术前外科医生可获得的信息。然后我们将最好的预测模型，MLR模型，转换成直观的nomogram来帮助患者进行咨询。

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引用次数: 0

Surgical management of atrioesophageal fistula after catheter ablation of atrial fibrillation: A French nationwide study 心房颤动导管消融后房食管瘘的外科治疗：一项法国全国性研究。

JTCVS open

Pub Date : 2024-12-01 DOI: 10.1016/j.xjon.2024.09.010

Ludovic Dupautet MD , Guillaume Lebreton MD, PhD , Gabriel Saiydoun MD , Thierry Bourguignon MD, PhD , Sébastien Frey MD , Christophe Beaufreton MD, PhD , Géraud Galvaing MD, MSc , Sébastien Cambier MD, MSc , Marc Filaire MD, PhD , Laura Filaire MD, MSc

Objective

The study objective was to assess the efficacity of different surgical strategies for atrioesophageal fistula after catheter ablation of atrial fibrillation.

Methods

Between January 2010 and April 2023, all patients with a diagnosis of atrioesophageal fistula or pericardo-esophageal fistula after catheter ablation of atrial fibrillation were analyzed retrospectively from the French database EPITHOR. Patients without surgical management were excluded.

Results

Eighteen patients were included, 15 with atrioesophageal fistula and 3 with pericardo-esophageal fistula. Median follow-up was 89.5 days with an overall survival of 50%. Five patients underwent esophageal stenting, 2 as a bridge-to-esophagectomy with 50% of survival and 3 in association with esophagus and left atrial direct repair with 66% survival. Primary esophageal repair with flap coverage was performed in 8 patients with 25% survival, most of them with sepsis and neurological failure. Seven patients had an esophagectomy with 71% survival, only 2 of them having a neurological failure. Among them, 5 patients underwent a restorative surgery and are still alive. Four patients had a retrosternal colon interposition, and 1 patient had an esogastric anastomosis. Risk factors for death were neurological failure (hazard ratio [HR], 4.91, 95% CI, 0.95-25.22; P = .0057) in univariate analysis and sepsis (HR, 6.25, 95% CI, 1.17-33.3; P = .032) in multivariate analysis. Esophagectomy tended to offer a survival benefit (HR, 0.163, 95% CI, 0.019-1.340; P = .092). The use of cardiopulmonary bypass did not significantly impact survival (HR, 1.953, 95% CI, 0.392-9.719; P = .413).

Conclusions

Aggressive surgical strategies for managing atrioesophageal fistula are mandatory to offer the best chance of survival.

目的：评价心房颤动导管消融后不同术式治疗心房食管瘘的疗效。方法：回顾性分析2010年1月至2023年4月期间，所有心房颤动导管消融后诊断为心房食管瘘或心包食管瘘的患者。未进行手术治疗的患者被排除在外。结果：本组共纳入18例患者，其中心房食管瘘15例，心包食管瘘3例。中位随访时间为89.5天，总生存率为50%。5例患者接受了食管支架置入术，2例作为桥至食管切除术，生存率为50%，3例与食管和左心房直接修复相关，生存率为66%。8例患者行食管皮瓣一期修复术，生存率为25%，其中大部分患者伴有败血症和神经功能衰竭。7例患者进行了食管切除术，71%的患者存活，其中只有2例出现神经功能衰竭。其中5例患者行恢复性手术，目前仍存活。4例胸骨后结肠间置，1例胃食管吻合。死亡的危险因素为神经功能衰竭(风险比[HR]， 4.91, 95% CI, 0.95-25.22；P = 0.0057)在单因素分析和脓毒症(HR, 6.25, 95% CI, 1.17-33.3；P = 0.032)。食管切除术倾向于提供生存获益(HR, 0.163, 95% CI, 0.019-1.340；p = .092)。体外循环的使用对生存率无显著影响(HR, 1.953, 95% CI, 0.392-9.719；p = .413)。结论：积极的手术策略是治疗房食管瘘的强制性措施，以提供最佳的生存机会。

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引用次数: 0