Journal: J Thorac Cardiovasc Surg

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<div><h4>Redefining \"low risk\": Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era.</h4><i>Johnston DR, Mahboubi R, Soltesz EG, Artis AS, ... Svensson LG, Cleveland Clinic Aortic Valve Center Collaborators</i><br /><b>Objectives</b><br />Guidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival.<br /><b>Methods</b><br />From January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality.<br /><b>Results</b><br />With 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex-matched population.<br /><b>Conclusions</b><br />STS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.<br /><br />Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Feb 2023; 165:591-604.e3</small></div>
Johnston DR, Mahboubi R, Soltesz EG, Artis AS, ... Svensson LG, Cleveland Clinic Aortic Valve Center Collaborators
J Thorac Cardiovasc Surg: 01 Feb 2023; 165:591-604.e3 | PMID: 36635021
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<div><h4>The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation.</h4><i>Expert Consensus Panel:, Hartwig M, van Berkel V, Bharat A, ... Puri V, Van Raemdonck D</i><br /><b>Objective</b><br />The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation.<br /><b>Methods</b><br />The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement.<br /><b>Results</b><br />The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively.<br /><b>Conclusions</b><br />Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Jan 2023; 165:301-326</small></div>
Expert Consensus Panel:, Hartwig M, van Berkel V, Bharat A, ... Puri V, Van Raemdonck D
J Thorac Cardiovasc Surg: 01 Jan 2023; 165:301-326 | PMID: 36517135
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<div><h4>The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot.</h4><i>Expert Consensus Panel:, Miller JR, Stephens EH, Goldstone AB, ... Emani SM, Eghtesady P</i><br /><b>Objective</b><br />Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice.<br /><b>Methods</b><br />The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement.<br /><b>Results</b><br />In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation.<br /><b>Conclusions</b><br />Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Jan 2023; 165:221-250</small></div>
Expert Consensus Panel:, Miller JR, Stephens EH, Goldstone AB, ... Emani SM, Eghtesady P
J Thorac Cardiovasc Surg: 01 Jan 2023; 165:221-250 | PMID: 36522807
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<div><h4>Temporary ventricular assist device support with a catheter-based axial pump: Changing the paradigm at a pediatric heart center.</h4><i>Tume SC, Fuentes-Baldemar AA, Anders M, Spinner JA, ... Qureshi AM, Adachi I</i><br /><b>Objective</b><br />We report the largest pediatric single-center experience with an Impella (Abiomed Inc) catheter-based axial pump support.<br /><b>Methods</b><br />We conducted a retrospective cohort study of all patients with acute decompensated heart failure or cardiogenic shock requiring catheter-based axial pump support between October 2014 and February 2022. The primary outcome per individual encounter (hospital admission) was defined as bridge-to-recovery, bridge-to-durable ventricular assist device support, bridge-to-cardiac transplantation, or death at 6 months after catheter-based axial pump explantation. Adverse events were defined according to the Pediatric Interagency Registry for Mechanical Circulatory Support criteria.<br /><b>Results</b><br />Our final study cohort included 37 encounters with 43 catheter-based axial pump implantations. A single catheter-based axial pump device was used for support in 33 encounters (89%), with 2 catheter-based axial pump devices used in 3 (8%) separate encounters and 3 catheter-based axial pump devices used in 1 (3%) encounter. The median [range] age, weight, and body surface area at implantation were 16.8 [6.9-42.8] years, 61.1 [23.1-123.8] kg, and 1.7 [0.8-2.5] m<sup>2</sup>, respectively. The predominant causes of circulatory failure were graft failure/rejection in 16 patients (43%), followed by cardiomyopathy in 7 patients (19%), arrhythmia refractory to medical therapies in 6 patients (16%), myocarditis/endocarditis in 4 patients (11%), and heart failure due to congenital heart disease in 4 patients (11%). Competing outcomes analysis showed a positive outcome with bridge-to-recovery in 58%, bridge-to-durable VAD support in 14%, and bridge-to-cardiac transplantation in 14% at 6 months. Fourteen percent of encounters resulted in death at 6 months.<br /><b>Conclusions</b><br />We demonstrate that catheter-based axial pump support in children results in excellent 1- and 6-month survival with an acceptable adverse event profile.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 24 Dec 2022; epub ahead of print</small></div>
Tume SC, Fuentes-Baldemar AA, Anders M, Spinner JA, ... Qureshi AM, Adachi I
J Thorac Cardiovasc Surg: 24 Dec 2022; epub ahead of print | PMID: 36681561
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<div><h4>Worse survival in patients with right ventricular dysfunction and COVID-19-associated acute respiratory distress requiring extracorporeal membrane oxygenation: A multicenter study from the ORACLE Group.</h4><i>Cain MT, Taylor LJ, Colborn K, Teman NR, ... Rove JY, ORACLE group</i><br /><b>Objective</b><br />We sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation.<br /><b>Methods</b><br />Six academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared.<br /><b>Results</b><br />The cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non-extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes.<br /><b>Conclusions</b><br />The presence of right ventricular dysfunction in patients with COVID-19-related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality.<br /><br />Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Dec 2022; epub ahead of print</small></div>
Cain MT, Taylor LJ, Colborn K, Teman NR, ... Rove JY, ORACLE group
J Thorac Cardiovasc Surg: 21 Dec 2022; epub ahead of print | PMID: 36717346
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<div><h4>Distal aortic progression following acute type A aortic dissection repair among patients with bicuspid and tricuspid aortic valves.</h4><i>Titsworth M, Graham NJ, Orelaru F, Ahmad RA, ... Deeb GM, Yang B</i><br /><b>Objective</b><br />The study objective was to analyze long-term growth and outcomes of the distal aorta after open acute type A aortic dissection repair in patients with bicuspid aortic valves or tricuspid aortic valves without connective tissue disease.<br /><b>Methods</b><br />From 1996 to 2021, 60 patients with bicuspid aortic valves and 655 patients with tricuspid aortic valves without connective tissue disease underwent open repair for acute type A aortic dissection. Data were collected from the local Society of Thoracic Surgeons database, medical record review, surveys, and the National Death Index and Michigan Death Index (December 12, 2021).<br /><b>Results</b><br />Compared with the tricuspid aortic valve group, the bicuspid aortic valve group was significantly younger, had more severe aortic insufficiency (33% vs 22%, P = .05), and had less hypertension (67% vs 78%, P = .05). Intraoperatively, patients with bicuspid aortic valves received more aortic root replacements (70% vs 26%, P < .001), less zone 2 aortic arch replacement (8.3% vs 20%, P = .03), and longer median cardiopulmonary bypass (233 vs 214 minutes, P = .05) and aortic crossclamp (184 vs 141 minutes, P < .001) times. The average annual aortic arch growth rate (0.23 mm/year vs 0.39 mm/year, P = .52) and descending aorta growth rate (0.61 mm/year vs 0.79 mm/year, P = .39) were similar between the bicuspid aortic valve and tricuspid aortic valve groups. The bicuspid aortic valve group had lower annual abdominal aorta growth (0.51 mm/year vs 0.68 mm/year, P = .03). The cumulative incidence of reoperation for the distal aorta (9.7% vs 16.0%, P = .77) was similar between the bicuspid aortic valve and tricuspid aortic valve groups. The 10-year survival was higher in the bicuspid aortic valve group (75.4% vs 66.0%, P = .03).<br /><b>Conclusions</b><br />Patients with bicuspid aortic valves could be treated similarly as patients with tricuspid aortic valves without connective tissue disease in the setting of open acute type A aortic dissection repair.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Dec 2022; epub ahead of print</small></div>
Titsworth M, Graham NJ, Orelaru F, Ahmad RA, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 21 Dec 2022; epub ahead of print | PMID: 36639287
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<div><h4>Outcomes of a protocolized approach for surgical unroofing of intramural anomalous aortic origin of coronary artery in children and adults.</h4><i>Patlolla SH, Stephens EH, Schaff HV, Anavekar NS, ... Julsrud PR, Dearani JA</i><br /><b>Objective</b><br />Management of anomalous aortic origin of coronary arteries has been variable, and limited data are available on early and late outcomes.<br /><b>Methods</b><br />We report a single institution\'s experience with a protocolized approach to 148 consecutive patients who underwent surgical unroofing of intramural anomalous aortic origin of coronary arteries (June 2003 to December 2020). The management algorithm included preoperative and postoperative cross-sectional and echocardiographic imaging, exercise testing, and a standardized operative technique.<br /><b>Results</b><br />The median age of the cohort was 44.4 years (range, 4 months to 83 years); 130 patients had an anomalous right coronary artery, and 19 patients had an anomalous left coronary artery. Surgical unroofing was an isolated procedure in 118 patients (80%) and a concomitant procedure in 30 patients (20.3%). There were 2 (1%) early deaths; both were reoperations for aortic root or valve replacement. Over a median follow-up of 9.5 (interquartile range, 5-12.3) years, there were 5 late deaths, 3 due to noncardiac causes and 2 due to unknown cause. Late survival after anomalous aortic origin of coronary arteries repair at 10 and 15 years was 94.5% and 94.5%, respectively. There were no early or late deaths in the pediatric cohort with a median follow-up of 10.9 years (interquartile range, 6.9-12.1). At a median clinical follow-up of 3.9 years (interquartile range, 1.1-9.5), 36 patients had chest pain but none with evidence of ischemia related to the unroofing.<br /><b>Conclusions</b><br />Surgical unroofing of anomalous aortic origin of coronary arteries can be performed safely with low early mortality, even in the setting of concomitant procedures. Late survival is excellent, with the vast majority being symptom free.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Dec 2022; epub ahead of print</small></div>
Patlolla SH, Stephens EH, Schaff HV, Anavekar NS, ... Julsrud PR, Dearani JA
J Thorac Cardiovasc Surg: 17 Dec 2022; epub ahead of print | PMID: 36690526
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<div><h4>Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non-small cell lung cancer.</h4><i>Mathey-Andrews C, McCarthy M, Potter AL, Beqari J, ... Raman V, Jeffrey Yang CF</i><br /><b>Objective</b><br />The objective of this study was to evaluate the feasibility of minimally invasive surgery (MIS) and perioperative outcomes following neoadjuvant immunotherapy for resectable non-small cell lung cancer (NSCLC).<br /><b>Methods</b><br />Patients with stage I to III NSCLC treated with immunotherapy with or without chemotherapy or chemotherapy alone prior to lobectomy were identified in the National Cancer Database (2010-2018). The percentage of operations performed minimally invasively, conversion rates, and perioperative outcomes were evaluated using propensity-score matching. Propensity-score matching was also used to compare perioperative outcomes between patients who underwent an open lobectomy and those who underwent an MIS lobectomy after neoadjuvant immunotherapy.<br /><b>Results</b><br />Of the 4229 patients identified, 218 (5%) received neoadjuvant immunotherapy and 4011 (95%) received neoadjuvant chemotherapy alone. There was no difference in the rate of MIS lobectomy among patients who received immunotherapy compared with those who received chemotherapy alone in propensity score-matched analysis (60.8% vs 51.6%; P = .11). There also were no significant differences in the rate of conversion from MIS to open lobectomy (14% vs 15%, P = .83; odds ratio, 1.1; 95% confidence interval, 0.51-2.24) or in nodal downstaging, margin positivity, 30-day readmission, and 30- and 90-day mortality between the 2 groups. In a subgroup analysis of only patients treated with neoadjuvant immunotherapy, there were no differences in pathologic or perioperative outcomes between patients who underwent open lobectomy and those who underwent MIS lobectomy.<br /><b>Conclusions</b><br />In this national analysis, neoadjuvant immunotherapy for resectable NSCLC was not associated with an increased likelihood of the need for thoracotomy, conversion from MIS to open lobectomy, or inferior perioperative outcomes.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 16 Dec 2022; epub ahead of print</small></div>
Mathey-Andrews C, McCarthy M, Potter AL, Beqari J, ... Raman V, Jeffrey Yang CF
J Thorac Cardiovasc Surg: 16 Dec 2022; epub ahead of print | PMID: 36653251
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<div><h4>Tumor thickness in mesothelioma predicts differential response to neoadjuvant therapy and survival.</h4><i>Zhou N, Bell CS, Feldman HA, Haymaker CL, ... Sepesi B, Mesothelioma Immune Genomic Group</i><br /><b>Objective</b><br />Neoadjuvant systemic therapy in resectable malignant pleural mesothelioma remains controversial and demonstrates variable responses. We sought to evaluate tumor thickness as a predictor of response to neoadjuvant therapy and as a prognostic marker for overall survival.<br /><b>Methods</b><br />Data from patients who underwent neoadjuvant therapy followed by cytoreductive surgery from 2002 to 2019 were reviewed. Baseline and postneoadjuvant therapy tumor thickness were measured on computed tomography. Radiological tumor response was categorized as progressive disease (≥20% increase), partial response (≥30% decrease), or stable disease (in between). Tumor response outcomes were modeled using logistic regression and multinomial regression models. Overall survival was evaluated based on tumor thickness and tumor response.<br /><b>Results</b><br />Of the 143 patients reviewed, 36 (25%) had progressive disease, 54 (38%) had stable disease, and 56 (39%) had partial response. The baseline tumor thickness of the progressive disease group (36 mm) was lower than in both stable disease and partial response groups (both 63 mm; P < .001). Both logistic regression and multinomial regression analyses demonstrated that thicker baseline tumor thickness was associated with decreased probability of progressive disease and increased probability of partial response. In a multivariable Cox model, thicker postneoadjuvant therapy tumor thickness was associated with worse overall survival (hazard ratio, 1.01, 95% confidence interval, 1.00-1.01, P = .008). The same trend was observed for thicker baseline tumor thickness (hazard ratio, 1.02, 95% confidence interval, 1.01-1.04, P = .008), and the risk was decreased in tumors with partial response (hazard ratio, 0.98, 95% confidence interval, 0.96-0.100, P = .014).<br /><b>Conclusions</b><br />We present the first study demonstrating the relationship between baseline tumor thickness and differential radiographic response to neoadjuvant therapy and survival. Further studies are needed to validate tumor thickness as both a prognostic and predictive biomarker.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 14 Dec 2022; epub ahead of print</small></div>
Zhou N, Bell CS, Feldman HA, Haymaker CL, ... Sepesi B, Mesothelioma Immune Genomic Group
J Thorac Cardiovasc Surg: 14 Dec 2022; epub ahead of print | PMID: 36737380
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<div><h4>Conduction mapping during complex congenital heart surgery: Creating a predictive model of conduction anatomy.</h4><i>Feins EN, O\'Leary ET, Davee J, Gauvreau K, ... Emani S, DeWitt ES</i><br /><b>Objectives</b><br />The study objectives were to report on a growing experience of conduction system mapping during complex congenital heart surgery and create a predictive model of conduction anatomy.<br /><b>Methods</b><br />Patients undergoing complex cardiac repair with conduction mapping were studied. Intraoperative mapping used a multielectrode catheter to collect His bundle electrograms in the open, decompressed, beating heart. Patient anatomy, operative details, His bundle location, and postoperative conduction status were analyzed. By using classification and regression tree analysis, a predictive model of conduction location was created.<br /><b>Results</b><br />A total of 109 patients underwent mapping. Median age and weight were 1.8 years (range, 0.2-14.9) and 10.8 kg (range, 3.5-50.4), respectively. Conduction was identified in 96% (105/109). Median mapping time was 6 minutes (range, 2-33). Anatomy included atrioventricular canal defect, double outlet right ventricle, complex transposition of the great arteries, and multiple ventricular septal defects. By classification and regression tree analysis, ventricular looping and visceroatrial situs were the greatest discriminators of conduction location. A total of 94 of 105 patients (89.5%) were free of complete heart block. Only 1 patient (2.9%) with heterotaxy syndrome developed complete heart block.<br /><b>Conclusions</b><br />The precise anatomic location of the conduction system in patients with complex congenital heart defects can be difficult for the surgeon to accurately predict. Intraoperative conduction mapping enables localization of the His bundle and adds to our understanding of the anatomic factors associated with conduction location. Predictive modeling of conduction anatomy may build on what is already known about the conduction system and help surgeons to better anticipate conduction location preoperatively and intraoperatively.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 13 Dec 2022; epub ahead of print</small></div>
Feins EN, O'Leary ET, Davee J, Gauvreau K, ... Emani S, DeWitt ES
J Thorac Cardiovasc Surg: 13 Dec 2022; epub ahead of print | PMID: 36710103
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<div><h4>Aortic root repair in acute type A aortic dissection: Neomedia or no neomedia.</h4><i>Ahmad RA, Orelaru F, Wu X, Kim KM, ... Deeb GM, Yang B</i><br /><b>Objective</b><br />Neomedia has been frequently used for aortic root repair in acute type A aortic dissection. We aimed to determine the efficacy and necessity of neomedia during acute type A aortic dissection root repair.<br /><b>Methods</b><br />From January 2010 to February 2021, 308 patients with acute type A aortic dissection underwent aortic root repair with neomedia (n = 132) or without neomedia (n = 176). Of these, 121 matched pairs were identified using propensity score matching based on age, sex, coronary artery disease, preoperative renal failure, acute stroke, prior cardiac surgery, cardiogenic shock, coronary malperfusion, preoperative cardiopulmonary resuscitation, and severe aortic insufficiency.<br /><b>Results</b><br />After matching, the preoperative demographics and comorbidities were well balanced in both groups. Compared with the neomedia group, the no neomedia group had less hemiarch (57% vs 69%, P = .05) and more zone 1 arch replacements (12% vs 4.1%, P = .03), shorter hypothermic circulatory arrest time (28 vs 36 minutes, P < .001), and shorter crossclamp time (120 vs 131 minutes, P = .02). Postoperative outcomes were similar, and the odds ratio by univariable logistic model of no neomedia for operative mortality was 0.83 (P = .76). Aortic root growth over 11 years (0.11 vs 0.16 mm/year, P = .66), 5-year freedom from greater than mild aortic insufficiency (84% vs 85%, P = .80), reoperation for root pathology (1 patient in each group), and 8-year survival (80% [95% confidence interval, 69-97] vs 71% [95% confidence interval, 55-82], P = .26) were similar between the neomedia and no neomedia groups.<br /><b>Conclusions</b><br />In patients with acute type A aortic dissection, aortic root repair with or without neomedia was equally safe and effective. Neomedia use could be avoided in acute type A aortic dissection repair.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 10 Dec 2022; epub ahead of print</small></div>
Ahmad RA, Orelaru F, Wu X, Kim KM, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 10 Dec 2022; epub ahead of print | PMID: 36621454
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<div><h4>Pacemaker implantation associated with tricuspid repair in the setting of mitral valve surgery: Insights from a Cardiothoracic Surgical Trials Network randomized trial.</h4><i>Ailawadi G, Voisine P, Raymond S, Gelijns AC, ... Gillinov M, trial investigators</i><br /><b>Objectives</b><br />In a recent trial, tricuspid annuloplasty (TA) during mitral valve surgery (MVS) for degenerative mitral regurgitation and moderate or less tricuspid regurgitation (TR) reduced the composite rate of death, reoperation for TR, or TR progression at 2 years. However, this benefit was counterbalanced by an increase in implantation of permanent pacemakers (PPMs). In this study, we analyzed the timing, indications, and risk factors for these implantations.<br /><b>Methods</b><br />We randomized 401 patients (MVS alone = 203; MVS + TA = 198). Potential risk factors for PPMs were assessed using multivariable time-to-event models with death and PPM implantation for heart failure indications as competing risks.<br /><b>Results</b><br />A PPM was implanted in 36 patients (9.6; 95% CI, 6.8-13.0) within 2 years of randomization, with 30/187 (16.0%) in the MVS + TA and 6/188 (3.2%) in the MVS groups (rate ratio, 5.08; 95% CI, 2.16-11.94; P < .001). Most (29/36; 80.6%) implantations occurred within 30 days postoperatively. Independent risk factors for PPM implantation within 2 years were TA (hazard ratio [HR], 5.94; 95% CI, 2.27-15.53; P < .001), increasing age (5 years, HR, 1.23; 95% CI, 1.01-1.52; P = .04), and left ventricular ejection fraction (LVEF; HR, 0.96; 95% CI, 0.92-0.99; P = .02). In the subset of TA recipients (n = 197), age (5 years, HR, 1.05; 95% CI, 1.00-1.10; P = .04) and LVEF (HR, 0.95; 95% CI, 0.91-0.99; P = .01) were associated with PPM within 2 years.<br /><b>Conclusions</b><br />Concomitant TA, age, and baseline LVEF were risk factors for PPM implantation in patients who underwent MVS for degenerative mitral regurgitation. Although TA was effective in preventing progression of TR, innovation is needed to identify ways to decrease PPM implantation rates.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 08 Dec 2022; epub ahead of print</small></div>
Ailawadi G, Voisine P, Raymond S, Gelijns AC, ... Gillinov M, trial investigators
J Thorac Cardiovasc Surg: 08 Dec 2022; epub ahead of print | PMID: 36669972
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<div><h4>Minimally invasive surgery is associated with decreased postoperative complications after esophagectomy.</h4><i>Dyas AR, Stuart CM, Bronsert MR, Schulick RD, McCarter MD, Meguid RA</i><br /><b>Background</b><br />Although some studies have compared esophagectomy outcomes by technique or approach, there is opportunity to strengthen our knowledge surrounding these outcomes. We aimed to perform a comprehensive comparison of esophagectomy postoperative complications.<br /><b>Methods</b><br />We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2007-2018). Esophagectomies were identified using Current Procedural Terminology codes and grouped by operative technique (Ivor Lewis, transhiatal, McKeown) and surgical approach (minimally invasive vs open esophagectomy). Twelve postoperative complications were compared. Significant complications underwent risk adjustment using multivariate logistic regression.<br /><b>Results</b><br />Analysis was performed on 13,457 esophagectomies: 11,202 (83.2%) open and 2255 (16.8%) minimally invasive. There were 7611 (56.6%) Ivor Lewis, 3348 (24.9%) transhiatal, and 2498 (18.6%) McKeown procedures. There were significant differences among the surgical techniques in 6 of 12 risk-adjusted complications. When comparing the outcomes of minimally invasive techniques, there were only significant differences in 2 of 12 complications: overall morbidity (minimally invasive Ivor Lewis 30.5%, minimally invasive transhiatal 43.4%, minimally invasive McKeown 40.3%, P = .0009) and infections (minimally invasive Ivor Lewis 15.4%, minimally invasive transhiatal 26.0%, minimally invasive McKeown 25.3%, P = .0003). Patients who underwent minimally invasive surgery were less likely to have overall morbidity (odds ratio, 0.68; 95% confidence interval, 0.62-0.75), respiratory complications (odds ratio, 0.77; 95% confidence interval, 0.68-0.87), urinary tract infection (odds ratio, 0.61; 95% confidence interval, 0.43-0.88), renal complications (odds ratio, 0.52; 95% confidence interval, 0.34-0.81), bleeding complications (odds ratio, 0.36; 95% confidence interval, 0.30-0.43), and nonhome discharge (odds ratio, 0.54; 95% confidence interval, 0.45-0.64), and had shorter length of stay (9.7 vs 13.2 days, P < .0001).<br /><b>Conclusions</b><br />Patients undergoing minimally invasive esophagectomy have lower rates of postoperative complications regardless of esophagectomy techniques. The minimally invasive approach was associated with reduced complication variance among 3 common esophagectomy techniques.<br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 05 Dec 2022; epub ahead of print</small></div>
Dyas AR, Stuart CM, Bronsert MR, Schulick RD, McCarter MD, Meguid RA
J Thorac Cardiovasc Surg: 05 Dec 2022; epub ahead of print | PMID: 36577613
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<div><h4>Comparison of robotic-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy: A propensity-matched study from a single high-volume institution.</h4><i>Ekeke CN, Kuiper GM, Luketich JD, Ruppert KM, ... Pennathur A, Sarkaria IS</i><br /><b>Objective</b><br />Robotic-assisted minimally invasive esophagectomy accounts for a growing proportion of esophagectomies, potentially due to improved technical capabilities simplifying the challenging aspects of standard minimally invasive esophagectomy. However, there is limited evidence directly comparing both operations. The objective is to evaluate the short-term and long-term outcomes of robotic-assisted minimally invasive esophagectomy in comparison with the minimally invasive esophagectomy approach for patients with esophageal cancer over a 7-year period at a high-volume center. The primary end points of this study were overall survival and disease-free survival. Secondary end points included operation-specific morbidity, lymph node yield, readmission status, and in-hospital, 30-day, and 90-day mortality.<br /><b>Methods</b><br />Patients who underwent robotic-assisted minimally invasive esophagectomy or standard minimally invasive esophagectomy over a 7-year period were identified from a prospectively maintained database. Inclusion criteria were patients with stage I to III disease, operations performed past the learning curve, and no evidence of scleroderma or cirrhosis. A 1:3 propensity match (robotic-assisted minimally invasive esophagectomy:minimally invasive esophagectomy) for multiple clinical covariates was performed to identify the final study cohort. Perioperative outcomes were compared between the 2 operations.<br /><b>Results</b><br />A total of 734 patients undergoing minimally invasive esophagectomy (n = 630) or robotic-assisted minimally invasive esophagectomy (n = 104) for esophageal cancer were identified. After exclusions and matching, a total cohort of 246 patients undergoing robotic-assisted minimally invasive esophagectomy (n = 65) or minimally invasive esophagectomy (n = 181) were identified. There was no difference in overall survival (P = .69) or disease-free survival (P = .70). There were no significant differences in rates of major morbidity: pneumonia (17% vs 17%, P = .34), chylothorax (8% vs 9%, P = .95), recurrent laryngeal nerve injury (0% vs 1.5%, P = 1), anastomotic leak (5% vs 4%, P = .49), intraoperative complications (9% vs 8%, P = .73), or complete resection rates (99% vs 96%, P = .68). There was no difference in in-hospital (P = .89), 30-day (P = .66) or 90-day mortality (P = .73) between both cohorts. The robotic-assisted minimally invasive esophagectomy cohort yielded a higher median lymph node harvest in comparison with the minimally invasive esophagectomy cohort (32 vs 29, P = .02).<br /><b>Conclusions</b><br />Robotic-assisted minimally invasive esophagectomy may improve lymphadenectomy in patients undergoing esophagectomy for cancer. Minimally invasive esophagectomy and robotic-assisted minimally invasive esophagectomy are otherwise associated with similar mortality, morbidity, and perioperative outcomes. Further prospective study is required to investigate whether improved lymph node resection may translate to improved oncologic outcomes.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 05 Dec 2022; epub ahead of print</small></div>
Ekeke CN, Kuiper GM, Luketich JD, Ruppert KM, ... Pennathur A, Sarkaria IS
J Thorac Cardiovasc Surg: 05 Dec 2022; epub ahead of print | PMID: 36732144
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<div><h4>Contemporary outcomes of the double switch operation for congenitally corrected transposition of the great arteries.</h4><i>Marathe SP, Chávez M, Schulz A, Sleeper LA, ... Del Nido PJ, Baird CW</i><br /><b>Objective</b><br />To determine the contemporary outcomes of the double switch operation (DSO) (ie, Mustard or Senning + arterial switch).<br /><b>Methods</b><br />A single-institution, retrospective review of all patients with congenitally corrected transposition of the great arteries undergoing a DSO.<br /><b>Results</b><br />Between 1999 and 2019, 103 patients underwent DSO with a Mustard (n = 93) or Senning (n = 10) procedure. Segmental anatomy was (S, L, L) in 93 patients and (I, D, D) in 6 patients. Eight patients had heterotaxy and 71 patients had a ventricular septal defect. Median age was 2.1 years (range, 1.8 months-40 years), including 34 patients younger than age 1 year (33%). Median weight was 10.9 kg (range, 3.4-64 kg). Sixty-one patients had prior pulmonary artery bands for a median of 1.1 years (range, 14 days-12.9 years; interquartile range, 0.7-3.1 years). Median intensive care unit and hospital lengths of stay were 5 and 10 days, respectively. Median follow-up was 3.4 years (interquartile range, 1-9.8 years) and 5.2 years (interquartile range, 2.3-10.7 years) in 79 patients with >1 year follow-up. At latest follow-up, aortic, mitral, tricuspid valve regurgitation, and left ventricle dysfunction was less than moderate in 96%, 98%, 96%, and 93%, respectively. Seventeen patients underwent reoperation: neoaortic valve intervention (n = 10), baffle revision (n = 5), and ventricular septal defect closure (n = 4). At latest follow-up, 17 patients (17%) had a pacemaker and 27 (26%) had cardiac resynchronization therapy devices. There were 2 deaths and 2 transplants. Transplant-free survival was 94.6% at 5 years. Risk factors for death or transplant included longer cardiopulmonary bypass time and older age at DSO.<br /><b>Conclusions</b><br />The outcomes of the DSO are promising. Earlier age at operation might favor better outcomes. Progressive neoaortic regurgitation and reinterventions on the neo-aortic valve are anticipated problems.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Dec 2022; 164:1980-1990.e7</small></div>
Marathe SP, Chávez M, Schulz A, Sleeper LA, ... Del Nido PJ, Baird CW
J Thorac Cardiovasc Surg: 01 Dec 2022; 164:1980-1990.e7 | PMID: 35688715
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<div><h4>Coronary access after repeat transcatheter aortic valve replacement in patients of small body size: A simulation study.</h4><i>Kawamura A, Maeda K, Shimamura K, Yamashita K, ... Sakata Y, Miyagawa S</i><br /><b>Background</b><br />Coronary artery access after repeat transcatheter aortic valve replacement (TAV-in-TAV) is reportedly more difficult because leaflet displacement of the first transcatheter heart valve (THV) impairs coronary cannulation; however, its effects in small patients are unknown. This study aimed to simulate coronary accessibility after TAV-in-TAV in patients of small body size.<br /><b>Methods</b><br />We retrospectively analyzed computed tomography scans after initial THV implantation and classified patients by THV and coronary artery location, valve-to-aorta distance, and valve-to-coronary distance. Risks were compared between the SAPIEN and CoreValve/Evolut series, among THV generations, and between bicuspid and tricuspid aortic valves in the CoreValve/Evolut series.<br /><b>Results</b><br />A total of 254 patients (SAPIEN series, n = 164; CoreValve/Evolut series, n = 90) were enrolled. The average body surface area of the patients was 1.44 m<sup>2</sup>. Patients were classified as \"feasible\" (26%), \"theoretically feasible with low risk\" (19.7%), \"theoretically feasible with high risk\" (8.7%), or \"unfeasible\" (45.8%). The \"unfeasible\" rate was significantly higher in the CoreValve/Evolut series than in the SAPIEN series (78.9% vs 26.2%; P < .001). A significantly higher \"unfeasible\" rate was identified in the current model of SAPIEN (SAPIEN, 8.3%; SAPIENXT, 1.8%; SAPIEN3, 48.2%; P < .001), but not in the CoreValve/Evolut series (CoreValve, 83.3%; Evolut R, 80.0%; Evolut PRO, 71.4%; P = .587). Patients with a bicuspid aortic valve had a lower \"unfeasible\" rate compared to those with a tricuspid aortic valve (60.0% vs 86.2%; P = .014).<br /><b>Conclusions</b><br />Patients of small body size may have a high probability of \"unfeasible\" coronary access after TAV-in-TAV, especially when treated with current high-frame devices, suggesting the need for careful strategic planning for initial THV implantation.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Dec 2022; epub ahead of print</small></div>
Kawamura A, Maeda K, Shimamura K, Yamashita K, ... Sakata Y, Miyagawa S
J Thorac Cardiovasc Surg: 01 Dec 2022; epub ahead of print | PMID: 36604286
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<div><h4>Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures: Deficiencies and opportunities for quality improvement.</h4><i>Kalfa D, Karamichalis JM, Singh SK, Jiang P, ... Habib A, Bacha E</i><br /><b>Objectives</b><br />We examined cases of operative mortality at a single quaternary academic center for patients undergoing relatively lower-risk (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1-3) procedures, as a means of identifying systemic weaknesses and opportunities for quality improvement.<br /><b>Methods</b><br />A retrospective review of all operative mortality events for patients who underwent a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1, 2, or 3 index procedure (2009-2020) at our institution was performed. After a detailed chart review was performed by 2 independent faculty for each case, factors and system deficiencies that contributed to mortality were identified.<br /><b>Results</b><br />A total of 42 mortalities were identified. A total of 37 patients (88%) had at least 1 Society of Thoracic Surgeons-designated risk factor, including prior cardiac operations (48%), extracardiac malformations (43%), and preoperative ventilation (33%). Eight patients (19%) had non-Society of Thoracic Surgeons-designated preoperative patient-level variables considered as at potential risk, including severe ventricular dysfunction, pulmonary hypertension, lung hypoplasia, and undiagnosed severe coronary abnormalities. Four patients (10%) had no identified preoperative risk factors. After detailed chart review, 5 broad categories were identified: patient-related factors (n = 33; 78%), postoperative infection (n = 13; 31%), postoperative residual lesions (n = 7; 17%), Fontan physiology failure (n = 4; 10%), and unexplained left ventricular failure after tetralogy of Fallot repair (n = 3; 7%). A total of 74% of patients had at least 1 preoperative, intraoperative, or postoperative system deficiency. A total of 50% of surgeries were urgent or emergency.<br /><b>Conclusions</b><br />Operative mortality after Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category 1 to 3 procedures is related to the presence of multifactorial risk patterns (Society of Thoracic Surgeons and non-Society of Thoracic Surgeons-designated patient-level risk factors and variables, broad risk categories, system deficiencies, emergency surgery). A multidisciplinary approach to care, with early recognition and treatment of modifiable additional burdens, could reduce this risk.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 30 Nov 2022; epub ahead of print</small></div>
Kalfa D, Karamichalis JM, Singh SK, Jiang P, ... Habib A, Bacha E
J Thorac Cardiovasc Surg: 30 Nov 2022; epub ahead of print | PMID: 36621456
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<div><h4>Long-term survival and center volume for functionally single-ventricle congenital heart disease in England and Wales.</h4><i>Brown KL, Huang Q, Hadjicosta E, Seale AN, ... Franklin R, Ridout D</i><br /><b>Objectives</b><br />Long-term survival is an important metric for health care evaluation, especially in functionally single-ventricle (f-SV) congenital heart disease (CHD). This study\'s aim was to evaluate the relationship between center volume and long-term survival in f-SV CHD within the centralized health care service of England and Wales.<br /><b>Methods</b><br />This was a retrospective cohort study of children born with f-SV CHD between 2000 and 2018, using the national CHD procedure registry, with survival ascertained in 2020.<br /><b>Results</b><br />Of 56,039 patients, 3293 (5.9%) had f-SV CHD. Median age at first intervention was 7 days (interquartile range [IQR], 4, 27), and median follow-up time was 7.6 years (IQR, 1.0, 13.3). The largest diagnostic subcategories were hypoplastic left heart syndrome, 1276 (38.8%); tricuspid atresia, 440 (13.4%); and double-inlet left ventricle, 322 (9.8%). The survival rate at 1 year and 5 years was 76.8% (95% confidence interval [CI], 75.3%-78.2%) and 72.1% (95% CI, 70.6%-73.7%), respectively. The unadjusted hazard ratio for each 5 additional patients with f-SV starting treatment per center per year was 1.04 (95% CI, 1.02-1.06), P < .001. However, after adjustment for significant risk factors (diagnostic subcategory; antenatal diagnosis; younger age, low weight, acquired comorbidity, increased severity of illness at first procedure), the hazard ratio for f-SV center volume was 1.01 (95% CI, 0.99-1.04) P = .28. There was strong evidence that patients with more complex f-SV (hypoplastic left heart syndrome, Norwood pathway) were treated at centers with greater f-SV case volume (P < .001).<br /><b>Conclusions</b><br />After adjustment for case mix, there was no evidence that f-SV center volume was linked to longer-term survival in the centralized health service provided by the 10 children\'s cardiac centers in England and Wales.<br /><br />Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print</small></div>
Brown KL, Huang Q, Hadjicosta E, Seale AN, ... Franklin R, Ridout D
J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print | PMID: 36535820
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<div><h4>Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty.</h4><i>Shraer N, Youssefi P, Zacek P, Debauchez M, ... Raisky O, Lansac E</i><br /><b>Objective</b><br />We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.<br /><b>Methods</b><br />Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty.<br /><b>Results</b><br />Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade >2 was 5.8% (n = 9), and grade >1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade >2 (1.2% vs 23.6%, P < .001) at 9 years. Initial commissural angle <160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle <160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029).<br /><b>Conclusions</b><br />BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle <160° is not associated with reoperation if symmetrical repair is achieved.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print</small></div>
Shraer N, Youssefi P, Zacek P, Debauchez M, ... Raisky O, Lansac E
J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print | PMID: 36535821
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<div><h4>Surgical ablation for atrial fibrillation is efficacious in patients with giant left atria.</h4><i>McGilvray MMO, Bakir NH, Yates TE, Kelly MO, ... Melby SJ, Damiano RJ</i><br /><b>Objective</b><br />The Cox-Maze IV procedure (CMP-IV) is the most effective treatment for atrial fibrillation. Increased left atrial (LA) size has been identified as a risk factor for failure to restore sinus rhythm. This has biased many surgeons against ablation in patients with giant left atrium (GLA), defined as LA diameter >6.5 cm. In this study we aimed to define the efficacy of the CMP-IV in patients with GLA.<br /><b>Methods</b><br />From April 2004 through March 2020, 786 patients with a documented LA diameter underwent elective CMP-IV, 72 of whom had GLA. Median follow-up duration was 4 years (interquartile range, 1-7 years). Recurrence was defined as any documented atrial tachyarrhythmia (ATA) lasting 30 seconds. ATA recurrence and survival were analyzed across GLA versus non-GLA groups.<br /><b>Results</b><br />Median age at surgery was 65 (interquartile range, 56-73) years. Median LA diameter within the GLA group was 7.0 (range, 6.6-10.0) cm. There were no differences in rates of postoperative complications for the 2 groups, including rate of postoperative stroke and pacemaker placement (GLA 14%; non-GLA 12%; P = .682). A trend toward increased 30-day mortality in the GLA group did not reach statistical significance (GLA 6%; non-GLA 2%; P = .051). Freedom from ATAs at 5 years postoperatively was comparable for the 2 groups (GLA 82%; non-GLA 84%).<br /><b>Conclusions</b><br />The CMP-IV had good efficacy in patients with GLA. Our results suggest that LA diameter >6.5 cm should not preclude a patient from undergoing surgical ablation for atrial fibrillation.<br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print</small></div>
McGilvray MMO, Bakir NH, Yates TE, Kelly MO, ... Melby SJ, Damiano RJ
J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print | PMID: 36642681
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<div><h4>Feasibility of shape-sensing robotic-assisted bronchoscopy for biomarker identification in patients with thoracic malignancies.</h4><i>Connolly JG, Kalchiem-Dekel O, Tan KS, Dycoco J, ... Baine MK, Bott MJ</i><br /><b>Objective</b><br />Molecular diagnostic assays require samples with high nucleic acid content to generate reliable data. Similarly, programmed death-ligand 1 (PD-L1) immunohistochemistry (IHC) requires samples with adequate tumor content. We investigated whether shape-sensing robotic-assisted bronchoscopy (ssRAB) provides adequate samples for molecular and predictive testing.<br /><b>Methods</b><br />We retrospectively identified diagnostic samples from a prospectively collected database. Pathologic reports were reviewed to assess adequacy of samples for molecular testing and feasibility of PD-L1 IHC. Tumor cellularity was quantified by an independent pathologist using paraffin-embedded sections. Univariable and multivariable linear regression models were constructed to assess associations between lesion- and procedure-related variables and tumor cellularity.<br /><b>Results</b><br />In total, 128 samples were analyzed: 104 primary lung cancers and 24 metastatic lesions. On initial pathologic assessment, ssRAB samples were deemed to be adequate for molecular testing in 84% of cases; on independent review of cellular blocks, median tumor cellularity was 60% (interquartile range, 25%-80%). Hybrid capture-based next-generation sequencing was successful for 25 of 26 samples (96%), polymerase chain reaction-based molecular testing (Idylla; Biocartis) was successful for 49 of 52 samples (94%), and PD-L1 IHC was successful for 61 of 67 samples (91%). Carcinoid and small cell carcinoma histologic subtype and adequacy on rapid on-site evaluation were associated with higher tumor cellularity.<br /><b>Conclusions</b><br />The ssRAB platform provided adequate tissue for next-generation sequencing, polymerase chain reaction-based molecular testing, and PD-L1 IHC in >80% of cases. Tumor histology and adequacy on intraoperative cytologic assessment might be associated with sample quality and suitability for downstream assays.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print</small></div>
Connolly JG, Kalchiem-Dekel O, Tan KS, Dycoco J, ... Baine MK, Bott MJ
J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print | PMID: 36621452
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<div><h4>Long-term outcomes of aortic root procedures for heterogenous ascending aneurysm disease in bicuspid aortic valve syndrome.</h4><i>Karianna Milewski RC, Habertheuer A, Bavaria JE, Suhail M, ... Szeto WY, Vallabhajosyula P</i><br /><b>Objective</b><br />Surgery for ascending aneurysms in bicuspid aortic valve syndrome primarily includes Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement (AVRSCAAR), and valve-sparing root reimplantation (VSRR). Comparative analysis of long-term clinical and functional outcomes of these procedures is detailed.<br /><b>Methods</b><br />From 1997 to 2017, 635 patients with bicuspid aortic valve undergoing root complex-focused procedures electively were stratified by valvulopathy (ie, aortic stenosis vs aortic insufficiency) and substratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences.<br /><b>Results</b><br />Kaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for aortic stenosis and aortic insufficiency presentations (log-rank P > .05). In patients with aortic stenosis, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (hazard ratio, 0.04; P = .013). Aortic reoperation rates were similar for biologic versus mechanical valves (P = .353). In patients with aortic insufficiency, similar long-term mortality (hazard ratio, 0.95; P = .93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient < 0.01; P < .001). Comparing Bentall to VSRR, mortality (hazard ratio, 0.12; P = .022) was significantly improved in patients undergoing VSRR, but recurrence of moderate or greater aortic insufficiency was higher in VSRR by multistate model (beta coefficient 2.63; P < .001).<br /><b>Conclusions</b><br />A tailored approach to heterogeneous ascending aneurysm pathologies in bicuspid aortic valve syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 24 Nov 2022; epub ahead of print</small></div>
Karianna Milewski RC, Habertheuer A, Bavaria JE, Suhail M, ... Szeto WY, Vallabhajosyula P
J Thorac Cardiovasc Surg: 24 Nov 2022; epub ahead of print | PMID: 36631305
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<div><h4>Emergency arterial switch: Rescue therapy for life-threatening hypoxemia in infants with transposition of great arteries with intact intraventricular septum.</h4><i>Hussey AD, Gentles TL, Perelini F, Beca J, Finucane K</i><br /><b>Objective</b><br />A small percentage of infants with d-loop transposition of the great arteries with intact intraventricular septum have life-threatening refractory hypoxemia often due to coexistent persistent pulmonary hypertension of the newborn. In this case series we describe the outcomes of a \"rescue\" emergency arterial switch operation (ASO).<br /><b>Methods</b><br />We undertook a retrospective medical record analysis of infants with d-loop transposition of the great arteries with intact intraventricular septum who underwent an ASO in New Zealand from January 1, 1996, to April 30, 2017. Data were compared for those who received an emergency ASO and those with a nonemergency ASO for descriptive purposes. An emergency ASO was defined as one that was undertaken for life-threatening refractory hypoxemia when the only alternative stabilization strategy was preoperative extracorporeal life support. Primary outcome measures were 30-day postoperative mortality and abnormal neurodevelopmental outcome in the survivors. Secondary outcomes were low cardiac output, arrhythmia, renal dysfunction, postoperative seizures, and length of stay. Other known risk factors for morbidity and mortality were also assessed.<br /><b>Results</b><br />Two hundred seventy-two infants underwent an ASO with 25 (9%) who received an emergency ASO. No infants received preoperative extracorporeal life support. The emergency group had greater 30-day postoperative mortality (8.0% vs 0.4%; P = .01) with no difference in abnormal neurodevelopmental outcome among the survivors (17.4% vs 13.8%; P = .35). The emergency group had more therapies for low cardiac output syndrome, more postoperative seizures, and a longer length of stay.<br /><b>Conclusions</b><br />An emergency ASO is a definitive rescue therapy that can be undertaken with acceptable mortality and neurodevelopmental outcome with consideration of the preoperative clinical state.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 22 Nov 2022; epub ahead of print</small></div>
Hussey AD, Gentles TL, Perelini F, Beca J, Finucane K
J Thorac Cardiovasc Surg: 22 Nov 2022; epub ahead of print | PMID: 36528432
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Abstract
<div><h4>Outcomes of pulmonary artery sling repair without tracheoplasty.</h4><i>Choi ES, Park CS, Kim DH, Kwon BS, ... Yu JJ, Yang DH</i><br /><b>Objective</b><br />This study aimed to investigate surgical outcomes of pulmonary artery (PA) sling without tracheoplasty.<br /><b>Methods</b><br />From 2001 through 2020, among 22 patients who underwent PA sling repair, all but 1 patient who underwent concomitant tracheal surgery were analyzed. The outcomes of interest were all-cause death, PA reintervention, tracheal intervention, and readmission for respiratory symptoms. Computed tomography was used to measure the narrowest tracheal diameter.<br /><b>Results</b><br />The median age and weight at repair were 7.6 months and 7.7 kg, respectively. Most patients (20 out of 21, 95.2%) had preoperative respiratory symptoms. Associated airway anomalies included tracheal ring in 12 (57.1%), bridging bronchus in 8 (38.1%), and tracheal bronchus in 2 patients (9.5%). There was 1 in-hospital death (4.8%). The median ventilator time and intensive care unit stay were 23 hours and 3 days, respectively. There was neither late death nor tracheal intervention during follow-up. Five patients (25.0%) underwent reintervention for left PA stenosis. Hospital readmission for respiratory symptom was required in 7 patients and was associated with the narrowest preoperative tracheal diameter (P = .025) and cardiopulmonary bypass time (P = .040) in univariable analysis. The narrowest tracheal diameter of 3.4 mm was identified as a cutoff value for readmission for respiratory symptom. Freedom from readmission for respiratory symptom was 63.3% at 10 years.<br /><b>Conclusions</b><br />PA sling repair without tracheal surgery might be a reasonable surgical option with rare need for tracheal intervention. Hospital readmissions for respiratory symptoms are more frequently required in patients with smaller tracheal diameter and all readmissions were limited to within 2 years after repair.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Nov 2022; epub ahead of print</small></div>
Choi ES, Park CS, Kim DH, Kwon BS, ... Yu JJ, Yang DH
J Thorac Cardiovasc Surg: 21 Nov 2022; epub ahead of print | PMID: 36528435
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Abstract
<div><h4>Racial disparities in thoracic aortic surgery: Myth or reality?</h4><i>Preventza O, Akpan-Smart E, Lubna K, Simpson K, ... LeMaire SA, Coselli JS</i><br /><b>Objective</b><br />We examined the relationship between Black or White race and adverse outcomes in patients who underwent surgery of the ascending aorta, aortic root, or aortic arch at our center.<br /><b>Methods</b><br />We analyzed 2335 consecutive patients who identified as Black (n = 217, 9.3%) or White (n = 2118, 90.7%) and underwent proximal aortic surgery. Patient zip codes were used to determine community socioeconomic (CSE) characteristics. The composite adverse outcome comprised mortality, persistent neurologic injury, and renal failure necessitating dialysis at discharge. We performed multivariable analysis, Kaplan-Meier analysis, and propensity score matching adjusted for CSE factors.<br /><b>Results</b><br />Median follow-up time was 3.7 years. Compared with White patients, Black patients lived in areas characterized by a higher percentage living below poverty level, lower income, and lower education level (P < .0001). Black patients had higher rates of emergency presentation (P < .0001) and lower 5- and 10-year survival rates (P = .0002). Short-term outcomes were similar between groups, except for respiratory failure and length of stay (P < .0001), which were higher in the Black population. After propensity score matching adjusted for CSE factors, Black and White patients (n = 204 each) had similar short-term outcomes and 5- and 10-year survival rates (P = .30). Multivariable analysis stratified by race showed that CSE factors independently predicted adverse outcomes in Black but not White patients.<br /><b>Conclusions</b><br />This is among few studies that have analyzed the relationship between race and proximal aortic surgery. Although outcomes were similar between Black and White patients in our cohort after adjusting for CSE factors, unfavorable CSE factors predicted adverse outcomes in Black but not White patients. More patient-specific studies are needed.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 18 Nov 2022; epub ahead of print</small></div>
Preventza O, Akpan-Smart E, Lubna K, Simpson K, ... LeMaire SA, Coselli JS
J Thorac Cardiovasc Surg: 18 Nov 2022; epub ahead of print | PMID: 36549985
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Abstract
<div><h4>Clinicopathologic outcomes of preoperative targeted therapy in patients with clinical stage I to III non-small cell lung cancer.</h4><i>Lengel HB, Zheng J, Tan KS, Liu CC, ... Isbell JM, Jones DR</i><br /><b>Objective</b><br />Targeted therapy improves outcomes in patients with advanced-stage non-small cell lung cancer (NSCLC) and in the adjuvant setting, but data on its use before surgery are limited. We sought to investigate the safety and feasibility of preoperative targeted therapy in patients with operable NSCLC.<br /><b>Methods</b><br />We retrospectively reviewed 51 patients with clinical stage I to III NSCLC who received targeted therapy, alone or in combination with chemotherapy, before surgical resection with curative intent, treated from 2004 to 2021. The primary outcome was the safety and feasibility of preoperative targeted therapy; secondary outcomes included objective response rate, major pathologic response (defined as ≤10% viable tumor) rate, recurrence-free survival (RFS), and overall survival.<br /><b>Results</b><br />Of the 51 patients included, 46 had an activating epidermal growth factor receptor gene alteration and 5 had an anaplastic lymphoma kinase fusion. Overall, 37 of 46 evaluable patients experienced at least 1 adverse event before surgery; however, only 3 patients experienced a grade 3 or 4 event. The objective response rate was 38% (17/45) for all evaluable patients and 44% (14/32) for patients with clinical stage II or III disease. The major pathologic response rate was 20% (9/44); 2 patients had a complete pathologic response. Median RFS was 3.8 years (95% CI, 2.8 to not reached). Targeted therapy alone was associated with better RFS than combination therapy (P = .009) in patients with clinical stage II or III disease.<br /><b>Conclusions</b><br />Preoperative targeted therapy was well tolerated and associated with good outcomes, with or without induction chemotherapy. In addition, radiographic response and pathologic response were strongly correlated.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Nov 2022; epub ahead of print</small></div>
Lengel HB, Zheng J, Tan KS, Liu CC, ... Isbell JM, Jones DR
J Thorac Cardiovasc Surg: 17 Nov 2022; epub ahead of print | PMID: 36528430
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<div><h4>Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation: Interim analysis of the TVVAD trial.</h4><i>Mendiola Pla M, Chiang Y, Nicoara A, Poehlein E, ... Milano CA, Bishawi M</i><br /><b>Objectives</b><br />Right heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation.<br /><b>Methods</b><br />Patients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery.<br /><b>Results</b><br />This report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events.<br /><b>Conclusions</b><br />The presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.<br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 16 Nov 2022; epub ahead of print</small></div>
Mendiola Pla M, Chiang Y, Nicoara A, Poehlein E, ... Milano CA, Bishawi M
J Thorac Cardiovasc Surg: 16 Nov 2022; epub ahead of print | PMID: 36639288
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Abstract
<div><h4>Pulmonary Open, Robotic, and Thoracoscopic Lobectomy study: Outcomes and risk factors of conversion during minimally invasive lobectomy.</h4><i>Herrera LJ, Schumacher LY, Hartwig MG, Bakhos CT, ... Vallières E, Kent MS</i><br /><b>Objective</b><br />Conversion to thoracotomy continues to be a concern during minimally invasive lobectomy. The aim of this propensity-matched cohort study is to analyze the outcomes and risk factors of intraoperative conversion during video-assisted thoracoscopic surgery (VATS) and robotic lobectomy (RL).<br /><b>Methods</b><br />Data from consecutive lobectomy cases performed for clinical stage IA to IIIA lung cancer was retrospectively collected from the Pulmonary Open, Robotic, and Thoracoscopic Lobectomy study consortium of 21 institutions from 2011 to 2019. The propensity-score method of inverse-probability of treatment weighting was used to balance the baseline characteristics across surgical approaches. Univariate logistic regression models were applied to test risk factors for conversion. Multivariable logistic regression analysis was conducted using a stepwise model selection method.<br /><b>Results</b><br />Seven thousand two hundred sixteen patients undergoing lobectomy were identified: RL (n = 2968), VATS (n = 2831), and open lobectomy (n = 1417). RL had lower conversion rate compared with VATS (3.6% vs 12.9%; P < .0001). In the multivariable regression model, tumor size and neoadjuvant therapy were the most significant risk factors for conversion, followed by prior cardiac surgery, congestive heart failure, chronic obstructive pulmonary disease, VATS approach, male gender, body mass index, and forced expiratory volume in 1 minute. Conversions for anatomical reasons were more common in VATS than RL (66.6% vs 45.6%; P = .0002); however, conversions for vascular reasons were more common in RL than VATS (24.8% vs 14%; P = .01). The rate of emergency conversions was comparable between RL and VATS (0.5% vs 0.7%; P = .25) with no intraoperative mortalities.<br /><b>Conclusions</b><br />Converted minimally invasive lobectomies were not associated with worse perioperative mortality compared with open lobectomy. Compared with VATS lobectomy, RL is associated with a lower probability of conversion in this propensity-score matched cohort study.<br /><br />Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 15 Nov 2022; epub ahead of print</small></div>
Herrera LJ, Schumacher LY, Hartwig MG, Bakhos CT, ... Vallières E, Kent MS
J Thorac Cardiovasc Surg: 15 Nov 2022; epub ahead of print | PMID: 36509569
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Abstract
<div><h4>Overestimation of screening-related complications in the National Lung Screening Trial.</h4><i>Kamel MK, Kariyawasam S, Stiles B</i><br /><b>Background</b><br />Lung cancer screening-associated complications are often quoted as one of the major barriers for wider screening adoption. A detailed analysis of the National Lung Screening Trial dataset was performed to extrapolate the safety of lung cancer screening.<br /><b>Methods</b><br />Lung cancer screening-associated invasive procedures and their related complications were analyzed using the National Lung Screening Trial dataset. Factors associated with 90-day postprocedure complications per patient were analyzed with logistic-regression multivariable analysis.<br /><b>Results</b><br />Major complications rate in patients undergoing low-dose computed tomography screening who were diagnosed with lung cancer was 10.2% compared with only 0.04% for patients without lung cancer. Low-dose computed tomography screening, compared with chest radiography, led to major complications in an excess of only 3.5 per 10,000 patients without lung cancer. Among 25,633 patients without lung cancer who underwent low-dose computed tomography screening, 45 developed 90-day postprocedure complications (71 total complications). The most common were pneumothorax (n = 29; 41%), postprocedure hospitalization (n = 6; 8.5%), and infection/fever requiring antibiotics (n = 5; 7%). Cardiac/respiratory arrest occurred in less than 1 in 10,000 low-dose computed tomography-screened patients without lung cancer. On multivariable analysis, pulmonary comorbidity (confidence interval, 1.00-3.37) and procedure type (thoracoscopy [confidence interval, 2.04-10.64] or thoracotomy [confidence interval, 2.38-8.93]) were associated with postprocedure complications in patients without lung cancer. Randomization arm (low-dose computed tomography vs chest x-ray) was not a significant factor (confidence interval, 0.89-1.37).<br /><b>Conclusions</b><br />It is more informative to report procedural complications in patients not found to have cancer as the true screening-associated risk. Only 4 in 10,000 of patients undergoing low-dose computed tomography screening but not found to have lung cancer will have major complications. Permanent or debilitating complications are exceedingly rare.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 14 Nov 2022; epub ahead of print</small></div>
Kamel MK, Kariyawasam S, Stiles B
J Thorac Cardiovasc Surg: 14 Nov 2022; epub ahead of print | PMID: 36503729
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Abstract
<div><h4>Molecular characterization and clinical investigation of patients with heritable thoracic aortic aneurysm and dissection.</h4><i>Yang H, Shen H, Zhu G, Shao X, ... Zhou Z, Shu C</i><br /><b>Objectives</b><br />Thoracic aortic aneurysm and dissection has a genetic predisposition and a variety of clinical manifestations. This study aimed to investigate the clinical and molecular characterizations of patients with thoracic aortic aneurysm and dissection and further explore the relationship between the genotype and phenotype, as well as their postoperative outcomes.<br /><b>Methods</b><br />A total of 1095 individuals with thoracic aortic aneurysm and dissection admitted to our hospital between 2013 and 2022 were included. Next-generation sequencing and multiplex ligation-dependent probe amplification were performed, and mosaicism analysis was additionally implemented to identify the genetic causes.<br /><b>Results</b><br />A total of 376 causative variants were identified in 83.5% of patients with syndromic thoracic aortic aneurysm and dissection and 18.7% of patients with nonsyndromic thoracic aortic aneurysm and dissection, including 8 copy number variations and 2 mosaic variants. Patients in the \"pathogenic\" and \"variant of uncertain significance\" groups had younger ages of aortic events and higher aortic reintervention risks compared with genetically negative cases. In addition, patients with FBN1 haploinsufficiency variants had shorter reintervention-free survival than those with FBN1 dominant negative variants.<br /><b>Conclusions</b><br />Our data expanded the genetic spectrum of heritable thoracic aortic aneurysm and dissection and indicated that copy number variations and mosaic variants contributed to a small proportion of the disease-causing alterations. Moreover, positive genetic results might have a possible predictive value for aortic event severity and postoperative risk stratification.<br /><br />Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 12 Nov 2022; epub ahead of print</small></div>
Yang H, Shen H, Zhu G, Shao X, ... Zhou Z, Shu C
J Thorac Cardiovasc Surg: 12 Nov 2022; epub ahead of print | PMID: 36517271
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<div><h4>Retrospective study of outcomes after extended resection for tracheobronchial adenoid cystic carcinoma.</h4><i>Estephan J, Mercier O, Thomas de Montpreville V, Hanna A, ... Fadel E, International Center for Thoracic Cancers Airway Cancer Working Group</i><br /><b>Objective</b><br />Tracheobronchial adenoid cystic carcinoma is a rare, slow-growing malignancy with a considerable propensity for local extension that may require complex airway resection to achieve tumor-free margins. The objective of this study was to assess whether our experience supports complex airway resection for tracheobronchial adenoid cystic carcinoma.<br /><b>Methods</b><br />Consecutive patients who underwent curative resection for tracheobronchial adenoid cystic carcinoma at our institution between 1970 and 2019 were included retrospectively and classified as having had complex or standard resection. Complex surgery included total tracheal replacement, associated esophageal resection, pneumonectomy, total laryngectomy with tracheal resection, and carinal resection. Standard surgery included tracheal resection, bronchoplastic resection, lobectomy, and bilobectomy. We obtained data from medical records, referring physicians, patients, relatives, and public death records.<br /><b>Results</b><br />Of 59 included patients, 38 had complex and 21 had standard surgery. All 4 (6.8%) patients who died postoperatively had undergone complex surgery. Postoperative morbidity was 32.2% overall and was significantly higher after complex surgery (P = .043). Overall 5- and 10-year survival rates were 81.5% and 60.2%, with no significant differences between groups (P = .31). By univariate analysis, T4 tumor and microscopically detectable tumor in the operative specimen margins and gross tumor in the operative specimen margins were associated with poorer survival (P < .05). In the subgroup with microscopically detectable tumor resection, survival was significantly better with adjuvant radiotherapy (P < .05).<br /><b>Conclusions</b><br />Complex resection for extended tracheobronchial adenoid cystic carcinoma may achieve local control and satisfying long-term survival. However, this demanding procedure is associated with high postoperative morbidity and mortality rates. Because adjuvant radiotherapy improved outcomes after resection resulting in microscopically detectable tumor in the operative specimen margins, expected outcomes after resection with no detectable tumor in the margins must be compared to those after resection resulting in microscopically detectable tumor in the margins plus radiotherapy, according to the operative risk.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 08 Nov 2022; epub ahead of print</small></div>
Estephan J, Mercier O, Thomas de Montpreville V, Hanna A, ... Fadel E, International Center for Thoracic Cancers Airway Cancer Working Group
J Thorac Cardiovasc Surg: 08 Nov 2022; epub ahead of print | PMID: 36528436
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This program is still in alpha version.