Journal: J Thorac Cardiovasc Surg

Sorted by: date / impact
Abstract

Modulation of inflammatory M1-macrophages phenotype by valvular interstitial cells.

Tagzirt M, Rosa M, Corseaux D, Vincent F, ... Susen S, Dupont A
Background
Aortic valve stenosis involves inflammation, excess deposition of a collagen-rich extracellular matrix, and calcification. Recent studies have shown that M1 or inflammatory macrophages derived from infiltrating monocytes promote calcification of valvular interstitial cells, the most prevalent cell type of the aortic valve. We hypothesized that valvular interstitial cells could modulate inflammatory macrophages phenotype.
Methods
We first assessed macrophage phenotype in human aortic valve stenosis and control aortic valves from donors. Then, we examined profibrotic and inflammatory-related gene expression in valves and valvular interstitial cells. Finally, we investigated whether valvular interstitial cells can modify the phenotype of inflammatory macrophages.
Results
Circulating monocytes and plasma transforming growth factor beta-1 levels of patients with aortic valve stenosis were significantly higher compared with patients without aortic valve stenosis. Histologic analysis of thickened spongiosa of the aortic valve from patients with aortic valve stenosis showed a high macrophage infiltration but a low matrix metalloproteinase-9 expression compared with control aortic valves. On the other hand, valvular interstitial cell culture of aortic valve stenosis exhibited a profibrotic phenotype with a high expression of transforming growth factor beta-1 and transforming growth factor beta-1/transforming growth factor beta-3 ratio but a decreased expression of the peroxisome proliferator-activated receptor gamma nuclear receptor. Valvular interstitial cell-conditioned media of aortic valve stenosis led to a decrease in enzymatic activity of matrix metalloproteinase-9 and an increase in production of collagen in inflammatory macrophages compared with valvular interstitial cell-conditioned media from control aortic valve donors.
Conclusions
These findings indicate that profibrotic valvular interstitial cells promote the imbalance of extracellular matrix remodeling by reducing matrix metalloproteinase-9 production on inflammatory macrophages that lead to excessive collagen deposition observed in aortic valve stenosis. Further investigation is needed to clarify the role of transforming growth factor beta-1/proliferator-activated receptor gamma nuclear receptor/matrix metalloproteinase-9 in aortic valve stenosis.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 28 Sep 2022; epub ahead of print
Tagzirt M, Rosa M, Corseaux D, Vincent F, ... Susen S, Dupont A
J Thorac Cardiovasc Surg: 28 Sep 2022; epub ahead of print | PMID: 36182586
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Abstract

Causal determinants of postoperative length of stay in cardiac surgery using causal graphical learning.

Lee JJR, Srinivasan R, Ong CS, Alejo D, ... Whitman GJR, Malinsky D
Objective
We aimed to learn the causal determinants of postoperative length of stay in cardiac surgery patients undergoing isolated coronary artery bypass grafting or aortic valve replacement surgery.
Methods
For patients undergoing isolated coronary artery bypass grafting or isolated aortic valve replacement surgeries between 2011 and 2016, we used causal graphical modeling on electronic health record data. The Fast Causal Inference (FCI) algorithm from the Tetrad software was used on data to estimate a Partial Ancestral Graph (PAG) depicting direct and indirect causes of postoperative length of stay, given background clinical knowledge. Then, we used the latent variable intervention-calculus when the directed acyclic graph is absent (LV-IDA) algorithm to estimate strengths of causal effects of interest. Finally, we ran a linear regression for postoperative length of stay to contrast statistical associations with what was learned by our causal analysis.
Results
In our cohort of 2610 patients, the mean postoperative length of stay was 219 hours compared with the Society of Thoracic Surgeons 2016 national mean postoperative length of stay of approximately 168 hours. Most variables that clinicians believe to be predictors of postoperative length of stay were found to be causes, but some were direct (eg, age, diabetes, hematocrit, total operating time, and postoperative complications), and others were indirect (including gender, race, and operating surgeon). The strongest average causal effects on postoperative length of stay were exhibited by preoperative dialysis (209 hours); neuro-, pulmonary-, and infection-related postoperative complications (315 hours, 89 hours, and 131 hours, respectively); reintubation (61 hours); extubation in operating room (-47 hours); and total operating room duration (48 hours). Linear regression coefficients diverged from causal effects in magnitude (eg, dialysis) and direction (eg, crossclamp time).
Conclusions
By using retrospective electronic health record data and background clinical knowledge, causal graphical modeling retrieved direct and indirect causes of postoperative length of stay and their relative strengths. These insights will be useful in designing clinical protocols and targeting improvements in patient management.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2022; epub ahead of print
Lee JJR, Srinivasan R, Ong CS, Alejo D, ... Whitman GJR, Malinsky D
J Thorac Cardiovasc Surg: 27 Aug 2022; epub ahead of print | PMID: 36154975
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Abstract

Advances in the treatment of postoperative recurrence of non-small cell lung cancer and their impact on survival in Asian patients.

Hashimoto K, Ariyasu R, Ichinose J, Matsuura Y, ... Nishio M, Mun M
Objectives
We investigated the effect of tyrosine kinase inhibitors (TKIs) and immunotherapy on survival after postoperative recurrence of non-small cell lung cancer (NSCLC).
Methods
This single-center retrospective study included patients with NSCLC who underwent lobectomy or more with complete pathological resection between 2008 and 2018 (N = 2254). Median follow-up was 5.1 years. Survival trends and the effect of TKIs/immunotherapy were analyzed using Joinpoint (National Cancer Institute) and Cox regression.
Results
In 443 (19.7%) postoperative recurrences, median time to recurrence was 1.1 years; epidermal growth factor receptor mutation (EGFR+), 191 (43.1%); anaplastic lymphoma kinase rearrangement (ALK+), 13 (2.9%); not detected or unknown (ND), 239 (54.0%). In multivariable analysis, age, time to recurrence, adenocarcinoma, symptomatic recurrence, any treatment for recurrence, use of the epidermal growth factor receptor TKI, use of the anaplastic lymphoma kinase TKI, and use of immunotherapy were significant prognostic factors. Survival was significantly better in the EGFR+/ALK+ group than in the ND group (median, 4.7 vs 2.1 years; P < .01). Between 2010 and 2018, 2-year postrecurrence survival improved significantly (annual percentage change [APC], 4.2; 95% CI, 1.5-7.0). In subset analyses, neither change in 2-year survival nor TKI use was significant over time in the EGFR+/ALK+ group, but the ND group experienced significant improvement in 2-year survival (APC, 13.5; 95% CI, 5.4-22.2) and increasing trend in immunotherapy use (APC, 23.0; 95% CI, -5.9 to 60) after 2013.
Conclusions
Survival after postoperative recurrence of NSCLC has improved significantly since 2010. Use of immunotherapy in patients without driver mutations may have contributed to that improvement. Prognosis in patients with driver mutations remains favorable with the TKIs introduced before the study period.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Aug 2022; epub ahead of print
Hashimoto K, Ariyasu R, Ichinose J, Matsuura Y, ... Nishio M, Mun M
J Thorac Cardiovasc Surg: 25 Aug 2022; epub ahead of print | PMID: 36137840
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Abstract

Persistent diastolic dysfunction in chronically ischemic hearts following coronary artery bypass graft.

Aggarwal R, Qi SS, So SW, Swingen C, ... Butterick TA, Kelly RF
Objective
A porcine model was used to study diastolic dysfunction in hibernating myocardium (HM) and recovery with coronary artery bypass surgery (CABG).
Methods
HM was induced in Yorkshire-Landrace juvenile swine (n = 30) by placing a c-constrictor on left anterior descending artery causing chronic myocardial ischemia without infarction. At 12 weeks, animals developed the HM phenotype and were either killed humanely (HIB group; n = 11) or revascularized with CABG and allowed 4 weeks of recovery (HIB+CABG group; n = 19). Control pigs were matched for weight, age, and sex to the HIB group. Before the animals were killed humanely, cardiac magnetic resonance imaging (MRI) was done at rest and during a low-dose dobutamine infusion. Tissue was obtained for histologic and proinflammatory biomarker analyses.
Results
Diastolic peak filling rate was lower in HIB compared with control (5.4 ± 0.7 vs 6.7 ± 1.4 respectively, P = .002), with near recovery with CABG (6.3 ± 0.8, P = .06). Cardiac MRI confirmed preserved global systolic function in all groups. Histology confirmed there was no transmural infarction but showed interstitial fibrosis in the endomysium in both the HIB and HIB+CABG groups compared with normal myocardium. Alpha-smooth muscle actin stain identified increased myofibroblasts in HM that were less apparent post-CABG. Cytokine and proteomic studies in HM showed decreased peroxisome proliferator-activator receptor gamma coactivator 1-alpha (PGC1-α) expression but increased expression of granulocyte-macrophage colony-stimulating factor and nuclear factor kappa-light-chain enhancer of activated B cells (NFκB). Following CABG, PGC1-α and NFκB expression returned to control whereas granulocyte-macrophage colony-stimulating factor, tumor necrosis factor-α, and interferon gamma remained increased.
Conclusions
In porcine model of HM, increased NFκB expression, enhanced myofibroblasts, and collagen deposition along with decreased PGC1-α expression were observed, all of which tended toward normal with CABG. Estimates of impaired relaxation with MRI within HM during increased workload persisted despite CABG, suggesting a need for adjuvant therapies during revascularization.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 24 Aug 2022; epub ahead of print
Aggarwal R, Qi SS, So SW, Swingen C, ... Butterick TA, Kelly RF
J Thorac Cardiovasc Surg: 24 Aug 2022; epub ahead of print | PMID: 36154976
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Abstract

Early outcomes following transatrial transcatheter mitral valve replacement in patients with severe mitral annular calcification.

Brener MI, Hamandi M, Hong E, Pizano A, ... Smith RL, George I
Objective
Implantation of a transcatheter valve-in-mitral annular calcification (ViMAC) has emerged as an alternative to traditional surgical mitral valve (MV) replacement. Previous studies evaluating ViMAC aggregated transseptal, transapical, and transatrial forms of the procedure, leaving uncertainty about each technique\'s advantages and disadvantages. Thus, we sought to evaluate clinical outcomes specifically for transatrial ViMAC from the largest multicenter registry to-date.
Methods
Patients with symptomatic MV dysfunction and severe MAC who underwent ViMAC were enrolled from 12 centers across the United States and Europe. Clinical characteristics, procedural details, and clinical outcomes were abstracted from the electronic record. The primary end point was all-cause mortality.
Results
We analyzed 126 patients who underwent ViMAC (median age 76 years [interquartile range {IQR}, 70-82 years], 28.6% female, median Society of Thoracic Surgeons score 6.8% [IQR, 4.0-11.4], and median follow-up 89 days [IQR, 16-383.5]). Sixty-one (48.4%) had isolated mitral stenosis, 25 (19.8%) had isolated mitral regurgitation (MR), and 40 (31.7%) had mixed MV disease. Technical success was achieved in 119 (94.4%) patients. Thirty (23.8%) patients underwent concurrent septal myectomy, and 8 (6.3%) patients experienced left ventricular outflow tract obstruction (7/8 did not undergo myectomy). Five (4.2%) patients of 118 with postprocedure echocardiograms had greater than mild paravalvular leak. Thirty-day and 1-year all-cause mortality occurred in 16 and 33 patients, respectively. In multivariable models, moderate or greater MR at baseline was associated with increased risk of 1-year mortality (hazard ratio, 2.31; 95% confidence interval, 1.07-4.99, P = .03).
Conclusions
Transatrial ViMAC is safe and feasible in this selected, male-predominant cohort. Patients with significant MR may derive less benefit from ViMAC than patients with mitral stenosis only.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Aug 2022; epub ahead of print
Brener MI, Hamandi M, Hong E, Pizano A, ... Smith RL, George I
J Thorac Cardiovasc Surg: 20 Aug 2022; epub ahead of print | PMID: 36153166
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Abstract

Prognostic value of recurrence pattern in locally advanced esophageal squamous cell carcinoma: Results from the phase III trial NEOCRTEC5010.

Chen D, Kong M, Sun J, Yang H, ... Shen J, Zhu C
Objectives
The prognosis of patients with locally advanced esophageal squamous cell carcinoma with different recurrence backgrounds is highly heterogeneous. This study aims to explore the effects of recurrence patterns on prognosis.
Methods
The phase III, multicenter, prospective NEOCRTEC5010 trial enrolled 451 patients with stage IIB-III esophageal squamous cell carcinoma randomly assigned to neoadjuvant chemoradiotherapy combined with surgery (NCRT group) or surgery alone (S group) and followed them long-term. We investigated the effects of recurrence patterns on survival in patients undergoing radical esophagectomy.
Results
In total, 353 patients were included in the study. The 5-year overall survival of patients with different recurrence patterns was significantly different: recurrence versus recurrence-free (17.8% vs 89.2%; P < .001), early recurrence versus late recurrence (4.6% vs 51.2%; P < .001), and distant metastasis versus locoregional recurrence (17.0% vs 20.0%; P = .666). Patients with early recurrence had significantly shorter survival after recurrence than those with late recurrence (hazard ratio, 1.541; 95% confidence interval, 1.047-2.268, P = .028). There was no significant difference in postrecurrence survival between patients with distant metastasis and locoregional recurrence (hazard ratio, 1.181; 95% confidence interval, 0.804-1.734; P = .396). Multivariate logistic analysis showed that pN1 stage, lymph node dissection <20, and lack of response to NCRT were independent risk factors for postoperative early recurrence. Multivariate Cox regression suggested that NCRT, age ≥60 years, early recurrence, and the pN1 stage were independent risk factors for shortened survival after recurrence.
Conclusions
Prerecurrence primary tumor stage is inaccurate in predicting postrecurrence survival. In contrast, recurrence patterns can guide follow-up while also predicting postrecurrence survival. NCRT prolongs disease-free survival but is associated with a worse prognosis in patients with recurrence, especially early recurrence.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Aug 2022; epub ahead of print
Chen D, Kong M, Sun J, Yang H, ... Shen J, Zhu C
J Thorac Cardiovasc Surg: 20 Aug 2022; epub ahead of print | PMID: 36137841
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Abstract

Outcomes following successful decannulation from extracorporeal life support for cardiogenic shock.

Zhang A, Kurlansky P, Ning Y, Wang A, ... Fried J, Takeda K
Objective
Although extracorporeal life support (ECLS) has increasingly been used for the treatment of patients with cardiogenic shock (CS), the outcomes of those successfully weaned from support remain poorly defined.
Methods
Of 510 venoarterial ECLS CS patients at our institution between January 2015 and December 2020, 249 were decannulated and survived for 30 days or until discharge (ie, successfully weaned). Factors associated with survival to discharge were assessed and 1-year survival was described.
Results
Of 510 eligible CS ECLS patients, 249 (48.8%) were successfully decannulated, 227 (44.5%) died during/following ECLS, and 34 (6.7%) were bridged to heart transplantation or a ventricular assist device. Patients with a primary graft dysfunction etiology of CS had a greater chance of successful decannulation (odds ratio [OR], 3.088; 95% CI, 1.1-8.671; P = .0323), whereas patients with ECLS during cardiopulmonary resuscitation had a reduced chance of successful decannulation (OR, 0.354; 95% CI, 0.17-0.735; P = .0054). Of successfully decannulated patients, 218 (87.6%) survived to hospital discharge and 31 (12.4%) died in the hospital. Acute myocardial infarction etiology (OR, 4.751; 95% CI, 1.623-13.902; P = .0044), preexisting chronic kidney disease (OR, 3.422; 95% CI, 1.374-8.52; P = .0082), and initiation of continuous renal replacement therapies (OR, 3.188; 95% CI, 1.291-7.871; P = .012) were significantly associated with in-hospital mortality despite successful decannulation. One-year survival in successfully decannulated patients surviving to hospital discharge was 95.0% and comparable to 1-year survival in patients who received a heart transplant or ventricular assist device.
Conclusions
Successful decannulation can be achieved in a significant proportion of patients treated with ECLS for CS but does not guarantee survival to hospital discharge. However, 1-year survival of hospital survivors remains high and is comparable to patients bridged to transplant or a ventricular assist device.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 19 Aug 2022; epub ahead of print
Zhang A, Kurlansky P, Ning Y, Wang A, ... Fried J, Takeda K
J Thorac Cardiovasc Surg: 19 Aug 2022; epub ahead of print | PMID: 36180251
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Abstract

Complete transcatheter versus surgical approach to aortic stenosis with coronary artery disease: A systematic review and meta-analysis.

Sakurai Y, Yokoyama Y, Fukuhara S, Takagi H, Kuno T
Objective
This meta-analysis aimed to evaluate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG).
Methods
The MEDLINE, EMBASE, and Cochrane Library databases were searched through November 2021 to identify studies comparing TAVR + PCI and SAVR + CABG for severe aortic stenosis with concurrent coronary artery disease. Outcomes of interest were all-cause mortality, repeat coronary intervention, rehospitalization, myocardial infarction, and stroke during follow-up, and 30-day periprocedural outcomes.
Results
Two randomized controlled trials and 6 observational studies including a total of 104,220 patients (TAVR + PCI, n = 5004; SAVR + CABG, n = 99,216) were included. The weighted mean follow-up period was 30.2 months. TAVR + PCI was associated with greater all-cause mortality and coronary reintervention during follow-up period (hazard ratio, 1.35; 95% confidence interval [CI], 1.11-1.65; P = .003, hazard ratio, 4.14; 95% CI, 1.74-9.86; P = .001, respectively), 30-day permanent pacemaker implantation rate (odds ratio [OR], 3.79; 95% CI, 1.61-8.95; P = .002), and periprocedural vascular complications (OR, 6.97; 95% CI, 1.85-26.30; P = .004). In contrast, TAVR + PCI was associated with a lower rate of 30-day acute kidney injury (OR, 0.32; 95% CI, 0.20-0.50; P = .0001). Rehospitalization, myocardial infarction, stroke during follow-up, and other periprocedural outcomes including 30-day mortality were similar in both groups.
Conclusions
In patients with severe aortic stenosis and coronary artery disease, TAVR + PCI was associated with greater all-cause mortality at follow-up compared with SAVR + CABG. Heart Team approach to assess TAVR candidacy remains imperative.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 18 Aug 2022; epub ahead of print
Sakurai Y, Yokoyama Y, Fukuhara S, Takagi H, Kuno T
J Thorac Cardiovasc Surg: 18 Aug 2022; epub ahead of print | PMID: 36150940
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Abstract

In-hospital thromboembolic complications after frozen elephant trunk aortic arch repair.

Ibrahim M, Chung JC, Ascaso M, Hage F, ... Peterson MD, Canadian Thoracic Aortic Collaborative
Objective
This study evaluated the frequency and clinical impact of thromboembolic complications after frozen elephant trunk aortic arch repair using the Thoraflex device (Terumo Aortic).
Methods
A total of 128 consecutive patients (mean age 67.9 ± 13.7 years, 31.0% female) underwent frozen elephant trunk aortic arch repair using the Thoraflex device between September 2014 and May 2021 in 4 Canadian centers. Patient baseline characteristics, intraoperative details, and frozen elephant trunk thromboembolic complications were collected retrospectively and analyzed.
Results
Fifteen patients (11.7%) had thrombus visualized within the frozen elephant trunk stent graft on imaging (n = 8; 53.3%) or had a thromboembolic event (n = 9; 60.0%) before hospital discharge. Sites of embolism were mesenteric (n = 8; 88.9%), renal (n = 4; 44.4%), and iliofemoral (n = 1; 11.1%). Patients who experienced thromboembolic complications were more likely to have a history of autoimmune disease (n = 3; 20.0% vs n = 2; 1.8%; P = .01) and implantation of a longer frozen elephant trunk stent graft (150 mm vs 100 mm) (n = 13; 86.7% vs n = 45; 39.8%; P < .001). All patients with thromboembolic complications received therapeutic anticoagulation, and a smaller proportion required an open surgical (n = 5; 33.3%) or an endovascular (n = 2; 13.3%) intervention. Radiographic resolution of thromboembolic complications was observed in 86.7% of patients (n = 13). In-hospital mortality occurred in 1 patient, stroke occurred in 1 patient, and transient spinal cord injury occurred in 1 patient.
Conclusions
Thromboembolic complications occur more often than previously recognized after frozen elephant trunk aortic arch repair using the Thoraflex device and are associated with increased rates of surgical and endovascular reintervention. Prevention and management of these complications require further study.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 17 Aug 2022; epub ahead of print
Ibrahim M, Chung JC, Ascaso M, Hage F, ... Peterson MD, Canadian Thoracic Aortic Collaborative
J Thorac Cardiovasc Surg: 17 Aug 2022; epub ahead of print | PMID: 36137836
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Abstract

Improvement in postoperative lung function in patients with moderate to severe airway obstruction after robotic-assisted thoracoscopic tracheobronchoplasty.

Inra ML, Wasserman GA, Karp J, Cohen S, Scheinerman SJ, Lazzaro RS
Objective
The study objective was to examine pulmonary function and quality of life improvement after robotic-assisted thoracoscopic tracheobronchoplasty for patients with different degrees of obstructive airway disease.
Methods
We performed a retrospective review of a prospective database of patients who underwent robotic-assisted thoracoscopic tracheobronchoplasty between 2013 and 2020.
Results
A total of 118 patients underwent robotic-assisted thoracoscopic tracheobronchoplasty. Preoperative and postoperative pulmonary function tests were available for 108 patients. Postoperative pulmonary function tests at a median of 16 months demonstrated a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 76.76% predicted, postoperative: 83% predicted, P = .002). Preoperative and postoperative St George Respiratory Questionnaires were available for 64 patients with a significant decrease in postoperative score at a median of 7 months (preoperative median: 61, postoperative: 41.60, P < .001). When stratified by preoperative degree of obstruction, robotic-assisted thoracoscopic tracheobronchoplasty improved forced expiratory volume in 1 second in moderate to very severe obstruction with a statistically significant improvement in moderate (preoperative median: 63.91% predicted, postoperative median: 73% predicted, P = .001) and severe (preoperative median: 44% predicted, postoperative median: 57% predicted, P = .007) obstruction. St George Respiratory Questionnaire scores improved for all patients. Improvement for mild (preoperative median: 61.27, postoperative median: 36.71, P < .001) and moderate (preoperative median: 57.15, postoperative median: 47.52, P = .03) obstruction was statistically significant.
Conclusions
Robotic-assisted thoracoscopic tracheobronchoplasty improves obstruction and symptoms. With limited follow-up, subgroup analysis showed forced expiratory volume in 1 second improved in severe preoperative obstruction and quality of life improved in moderate obstruction. Future follow-up is required to determine robotic-assisted thoracoscopic tracheobronchoplasty effects on the most severe group, but we cannot conclude that increased degree of preoperative obstruction precludes surgery.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 17 Aug 2022; epub ahead of print
Inra ML, Wasserman GA, Karp J, Cohen S, Scheinerman SJ, Lazzaro RS
J Thorac Cardiovasc Surg: 17 Aug 2022; epub ahead of print | PMID: 36137839
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Impact:
Abstract

Modified single-patch repair for atrioventricular septal defects results in good functional outcomes in the absence of deep ventricular septal defects.

Kobayashi Y, Kasahara S, Sano S, Kotani Y
Objectives
We compared 2-patch repair (TP) with modified single-patch repair (MSP) for complete atrioventricular septal defects and evaluated their effect on the left atrioventricular valve (LAVV) competence. We also identified risk factors for unfavorable functional outcomes.
Methods
This retrospective study included 118 patients with complete atrioventricular septal defects who underwent intracardiac repair from 1998 to 2020 (MSP: 69; TP: 49). The median follow-up period was 10.4 years. The functional outcome of freedom from moderate or greater LAVV regurgitation (LAVVR) was estimated using the Kaplan-Meier method.
Results
The hospital mortality was 1.7% (2/118) and late mortality was 0.8% (1/118). Eight patients required LAVV-related reoperation (MSP: 4; TP: 4) and none required left ventricular outflow tract-related reoperation. In the MSP group without LAVV anomaly, the receiver operating characteristic curve analysis revealed that the ventricular septal defect (VSD) depth was strongly associated with moderate or greater postoperative LAVVR, with the best cutoff at 10.9 mm. When stratified according to the combination of intracardiac repair type and VSD depth, the MSP-deep VSD (VSD depth >11 mm) group showed the worst LAVV competence among the 4 groups (P = .002). According to multivariate analysis, weight <4.0 kg, LAVV anomaly, and moderate or greater preoperative LAVVR were independent risk factors for moderate or greater postoperative LAVVR, whereas MSP was not a risk factor.
Conclusions
Postoperative LAVVR remains an obstacle to improved functional outcomes. MSP provides LAVV competence similar to TP unless deep VSD is present. The surgical approach should be selected on the basis of anatomical variations, specifically VSD depth.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 13 Aug 2022; epub ahead of print
Kobayashi Y, Kasahara S, Sano S, Kotani Y
J Thorac Cardiovasc Surg: 13 Aug 2022; epub ahead of print | PMID: 36115701
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Abstract

Surgical repair of peripheral pulmonary artery stenosis: A 2-decade experience with 145 patients.

Felmly LM, Mainwaring RD, Collins RT, Lechich K, ... Ma M, Hanley FL
Background
Peripheral pulmonary artery stenosis (PPAS) is a relatively rare form of congenital heart disease often associated with Williams syndrome, Alagille syndrome, and elastin arteriopathy. This disease is characterized by stenoses at nearly all lobar and segmental ostia and results in systemic-level right ventricular pressures. The current study summarizes our experience with the surgical treatment of PPAS.
Methods
This was a retrospective review of 145 patients who underwent surgical repair of PPAS. This included 43 patients with Williams syndrome, 39 with Alagille syndrome, and 21 with elastin arteriopathy. Other diagnoses include tetralogy of Fallot with PPAS (n = 21), truncus arteriosus (n = 5), transposition (n = 3), double-outlet right ventricle (n = 2), arterial tortuosity syndrome (n = 3), and other (n = 8).
Results
The median preoperative right ventricle to aortic peak systolic pressure ratio was 1.01 (range, 0.50-1.60) which was reduced to 0.30 (range, 0.17-0.60) postoperatively. The median number of ostial repairs was 17 (range, 6-34) and median duration of cardiopulmonary bypass was 398 minutes (range, 92-844). There were 3 in-hospital deaths (2.1%). The median duration of follow-up was 26 months (range, 1-220) with 4 late deaths (2.9%). Eighty-two patients have subsequently undergone catheterization and 74 had a pressure ratio <0.50.
Conclusions
The surgical treatment of PPAS resulted in a 70% reduction in right ventricular pressures. At 3 years, freedom from death was 94% and 90% of those evaluated maintained low pressures. These results suggest that the surgical treatment of PPAS is highly effective in most patients.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 10 Aug 2022; epub ahead of print
Felmly LM, Mainwaring RD, Collins RT, Lechich K, ... Ma M, Hanley FL
J Thorac Cardiovasc Surg: 10 Aug 2022; epub ahead of print | PMID: 36088147
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Impact:
Abstract

Blood type O heart transplant candidates have longer waitlist time and higher delisting under the new allocation system.

Eapen S, Nordan T, Critsinelis AC, Li B, ... Couper GS, Kawabori M
Objective
Prior studies have examined the effect of blood type on heart transplantation (HTx) waitlist outcomes in cohorts through 2015. We aim to analyze the effect of blood type on contemporary waitlist outcomes with a new allocation system focus.
Methods
Adults listed for HTx between April 2015 and December 2020 were included. Survival to HTx and waitlist death/deterioration was compared between type O and non-type O candidates using competing risks regression. Donor/recipient ABO compatibility trends were further investigated.
Results
Candidates with blood type O (n = 7509) underwent HTx less frequently than candidates with blood type other than type O (n = 9699) (subhazard ratio [sHR], 0.56; 95% CI, 0.53-0.58) with higher rates of waitlist death/deterioration (sHR, 1.18; 95% CI, 1.04-1.34). Subgroup analyses demonstrated persistence of this trend under the new donor heart allocation system (HTx: sHR, 0.58; 95% CI, 0.54-0.62; death/clinical deterioration: sHR, 1.27; 95% CI, 1.02-1.60), especially among those listed at high status (1, 2, or 3) (HTx: sHR, 0.69; 95% CI, 0.63-0.75; death/deterioration: sHR, 1.61; 95% CI, 1.16-2.22). Among those listed at status 3, waitlist death/deterioration was modified by presence of a durable left ventricular assist device (left ventricular assist device: sHR, 1.57; 95% CI, 0.58-4.29; no left ventricular assist device: sHR, 3.79; 95% CI, 1.28-11.2). Type O donor heart allocation to secondary ABO candidates increased in the new system (14.5% vs 12.0%; P < .01); post-HTx survival remained comparable between recipients with blood type O and non-type O (log-rank P = .07).
Conclusions
Further logistical considerations are warranted to minimize allocation inequity regarding blood type under the new allocation system.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Aug 2022; epub ahead of print
Eapen S, Nordan T, Critsinelis AC, Li B, ... Couper GS, Kawabori M
J Thorac Cardiovasc Surg: 08 Aug 2022; epub ahead of print | PMID: 36100474
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Impact:
Abstract

Impact of stereotactic body radiation therapy volume on surgical patient selection, short-term survival, and long-term survival in early-stage non-small cell lung cancer.

Till BM, Mack S, Whitehorn G, Rahman U, ... Evans NR, Okusanya O
Objectives
Stereotactic body radiation therapy (SBRT) is increasingly used to treat non-small cell lung cancer. The purpose of this study is to analyze relationships between facility SBRT utilization and surgical patient selection and survival after surgery.
Methods
Data on patients with TI/T2N0M0 lesions and treatment facility characteristics were abstracted from the National Cancer Database, 2008 to 2017. Facilities were stratified using an SBRT/surgery ratio previously associated with short-term survival benefit for patients treated surgically, and by a previously identified surgical volume threshold. Multiple regression analyses, Cox proportional-hazard regressions, and Kaplan-Meier log rank test were employed.
Results
In total, 182,610 patients were included. Proportion of high SBRT:surgery ratio (≥17%) facilities increased from 118 (11.5%) to 558 (48.4%) over the study period. Patients undergoing surgery at high-SBRT facilities had comparable comorbidity scores and tumor sizes to those at low-SBRT facilities, and nonclinically significant differences in age, race, and insurance status. Among low-volume surgical facilities, treatment at a high SBRT-using facility was associated with decreased 30-day mortality (1.8% vs 1.4%, P < .001) and 90-day mortality (3.3% vs 2.6%, P < .001). At high-volume surgical facilities, no difference was observed. At 5 years, a survival advantage was identified for patients undergoing resection at facilities with high surgical volumes (hazard ratio, 0.91; confidence interval, 0.90-0.93 P < .001) but not at high SBRT-utilizing facilities.
Conclusions
Differences in short-term survival following resection at facilities with high-SBRT utilization may be attributable to low surgical volume facilities. Patients treated at high volume surgical facilities do not demonstrate differences in short-term or long-term survival based on facility SBRT utilization.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print
Till BM, Mack S, Whitehorn G, Rahman U, ... Evans NR, Okusanya O
J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print | PMID: 36088141
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Impact:
Abstract

Transcatheter mitral valve implantation versus conventional redo surgery for degenerated mitral valve prostheses and rings in a multicenter registry.

Szlapka M, Hausmann H, Timm J, Bauer A, ... Nagib R, Arbeitsgemeinschaft Leitender herzchirurgischer Krankenhausärzte e.V. (ALHK) Study Group
Objectives
Degeneration of mitral prostheses/rings may be treated by redo surgery, and, recently, by transcatheter valve-in-valve/ring implantation. This multicenter registry presents results of transcatheter valve-in-valve and repeat surgery for prostheses/rings degeneration.
Methods
Data provided by 10 German heart centers underwent propensity score-matched retrospective analysis. The primary endpoint was 30-day/midterm mortality. Perioperative outcome was assessed according to the Mitral Valve Academic Research Consortium criteria. Further, the influence of moderate or greater tricuspid regurgitation (TR) on 30-day/midterm mortality was analyzed.
Results
Between 2014 and 2019, 273 patients (79 transcatheter mitral valve-in-valve [TM-ViV] and 194 redo mitral valve replacement [Re-MVR]) underwent repeat procedure for mitral prosthesis/ring degeneration. Propensity score matching distinguished 79 patient pairs. European System for Cardiac Operative Risk Evaluation (EuroSCORE) II-predicted risk was 15.7 ± 13.7% in the TM-ViV group and 15.0% ± 12.7% in the Re-MVR group (P = .5336). TM-ViV patients were older (74.73 vs 72.2 years; P = .0030) and had higher incidence of atrial fibrillation (54 vs 40 patients; P = .0233). Severe TR incidence was similar (17.95% in TM-ViV vs 14.10%; P = .1741). Sixty-eight TM-ViV patients previously underwent mitral valve replacement, whereas 41 Re-MVR patients underwent valve repair (P < .0001). Stenosis was the leading degeneration mechanism in 42 TM-ViV versus 22 Re-MVR patients (P < .0005). The 30-day/midterm mortality did not differ between groups. Moderate or greater TR was a predictor of total (odds ratio [OR], 4.36; P = .0011), 30-day (OR, 3.76; P = .0180), and midterm mortality (OR, 4.30; P = .0378), irrespective of group.
Conclusions
In both groups, observed mortality was less than predicted. Redo surgery enabled treatment of concomitant conditions, such as atrial fibrillation or TR. TR was shown to be a predictor of total, 30-day, and midterm mortality in both groups.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print
Szlapka M, Hausmann H, Timm J, Bauer A, ... Nagib R, Arbeitsgemeinschaft Leitender herzchirurgischer Krankenhausärzte e.V. (ALHK) Study Group
J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print | PMID: 36088142
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Impact:
Abstract

Living-donor segmental lung transplantation for pediatric patients.

Nakajima D, Tanaka S, Ikeda T, Baba S, ... Ohsumi A, Date H
Objective
The preset study evaluated the outcome of living-donor segmental lung transplantation for pediatric patients.
Methods
Between August 2009 and May 2021, we performed living-donor segmental lung transplantation in 6 critically ill pediatric patients, including 1 patient on a ventilator alone and another patient on a ventilator and extracorporeal membrane oxygenation (ECMO). There were 4 male and 2 female patients, with a median age of 7 years (range, 4-15 years) and a median height of 112.7 cm (range, 95-125.2 cm). The diagnoses included complications of allogeneic hematopoietic stem cell transplantation (n = 4) and pulmonary fibrosis (n = 2). All patients received bilateral lung transplantation under cardiopulmonary bypass. A basal segment and a lower lobe were implanted in 3 patients, and a basal segment and an S6 segment were implanted in the other 3 patients. In 2 patients, the right S6 segmental graft was horizontally rotated 180° and implanted as the left lung.
Results
Among the 9 segmental grafts implanted, 7 functioned well after reperfusion. Two rotated S6 segmental grafts became congestive, with 1 requiring graft extraction and the other venous repair, which was successful. There was 1 hospital death (14 days) due to sepsis and 1 late death (9 years) due to leukoencephalopathy. The remaining 4 patients are currently alive at 9 months, 10 months, 1.3 years, and 1.9 years.
Conclusions
Living-donor segmental lung transplantation was a technically difficult but feasible procedure with acceptable outcomes for small pediatric patients with chest cavities that were too small for adult lower lobe implantation.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print
Nakajima D, Tanaka S, Ikeda T, Baba S, ... Ohsumi A, Date H
J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print | PMID: 36088146
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Impact:
Abstract

Influence of intraoperative residual lesions and timing of extracorporeal membrane oxygenation on outcomes following first-stage palliation of single-ventricle heart disease.

Sengupta A, Gauvreau K, Kaza A, Allan C, ... Del Nido PJ, Nathan M
Background
Data regarding the influence of intraoperative residual lesions on extracorporeal membrane oxygenation (ECMO) following the Norwood procedure are limited. Moreover, the significance of postoperative ECMO timing on in-hospital outcomes remains incompletely characterized.
Methods
This was a single-center, retrospective review of consecutive patients who underwent the Norwood operation from January 1997 to November 2017. Patients with at least minor residual lesions based on the intraoperative postcardiopulmonary bypass echocardiogram were identified. The association between residual lesions and postoperative ECMO was assessed with logistic regression, adjusting for age, weight, prematurity, various preoperative system-specific and procedural risk factors, shunt type, and era. Among patients receiving ECMO, associations between late ECMO (≥3 days post-Norwood) and in-hospital mortality or transplant, postoperative hospital length-of-stay, and cost of hospitalization were evaluated using logistic regression or generalized linear models with a gamma distribution and logarithmic link.
Results
Among 500 patients, 78 (15.6%) received ECMO postoperatively. On multivariable analysis, the presence of at least minor residual lesions (odds ratio, 4.4; 95% CI, 2.1-9.3; P < .001) was associated with postoperative ECMO. In the ECMO subpopulation, there were 44 (56.4%) deaths or transplants. Late ECMO was associated with increased risk of in-hospital mortality or transplant (adjusted odds ratio, 6.2; 95% CI, 1.5-26.0), longer postoperative hospital length of stay (regression coefficient, 0.7; 95% CI, 0.3-1.1), and greater cost (regression coefficient, 0.6; 95%, CI 0.4-0.7), versus early ECMO (all P values < .05).
Conclusions
The presence of even minor intraoperative residua significantly increases the risk of ECMO following the Norwood operation. Among patients receiving ECMO postoperatively, early institution of ECMO is associated with lower mortality and resource utilization.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print
Sengupta A, Gauvreau K, Kaza A, Allan C, ... Del Nido PJ, Nathan M
J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print | PMID: 36058745
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Impact:
Abstract

Surgical resection after neoadjuvant durvalumab and radiation is feasible and safe in non-small cell lung cancer: Results from a randomized trial.

Lee B, Mynard N, Nasar A, Villena-Vargas J, ... Port J, Altorki N
Objective
Several trials have recently reported the safety of pulmonary resection after neoadjuvant immunotherapy with encouraging major pathological response rates. We report the detailed adverse events profile from a recently conducted randomized phase II trial in patients with resectable non-small cell lung cancer treated with neoadjuvant durvalumab alone or with sub-ablative radiation.
Methods
We conducted a randomized phase II trial in patients with non-small cell lung cancer clinical stages I to IIIA who were randomly assigned to receive neoadjuvant durvalumab alone or with sub-ablative radiation (8Gyx3). Secondary end points included the safety of 2 cycles of preoperative durvalumab with and without radiation followed by pulmonary resection. Postoperative adverse events within 30 days were recorded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0).
Results
Sixty patients were enrolled and randomly assigned, with planned resection performed in 26 patients in each arm. Baseline demographics and clinical variables were balanced between groups. The median operative time was similar between arms: 128 minutes (97-201) versus 146 minutes (109-214) (P = .314). There was no 30- or 90-day mortality. Grade 3/4 adverse events occurred in 10 of 26 patients (38%) after monotherapy and in 10 of 26 patients (38%) after dual therapy. Anemia requiring transfusion and hypotension were the 2 most common adverse events. The median length of stay was similar between arms (5 days vs 4 days, P = .172).
Conclusions
In this randomized trial, the addition of sub-ablative focal radiation to durvalumab in the neoadjuvant setting was not associated with increased mortality or morbidity compared with neoadjuvant durvalumab alone.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print
Lee B, Mynard N, Nasar A, Villena-Vargas J, ... Port J, Altorki N
J Thorac Cardiovasc Surg: 06 Aug 2022; epub ahead of print | PMID: 36028357
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Impact:
Abstract

Robotic degenerative mitral repair: Factors associated with intraoperative revision and impact of mild residual regurgitation.

Chen Q, Roach A, Trento A, Rowe G, ... Bowdish ME, Chikwe J
Objectives
National registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR.
Methods
A prospective institutional registry of 858 patients with degenerative MR undergoing robotic mitral surgery was linked to statewide databases. Univariate logistic regression identified factors associated with intraoperative repair revision. Survival was estimated using the Kaplan-Meier method and adjusted with Cox regression. Late freedom from more-than-moderate MR or reintervention was estimated with death as a competing risk.
Results
Repair rate was 99.3%. Repair was revised intraoperatively in 19 patients and was associated with anterior or bileaflet prolapse, adjunctive repair techniques, and annuloplasty band size (all P < .05). Intraoperative repair revision did not result in increased postoperative complications. Intraoperative mild residual MR (n = 111) was independently associated with inferior 8-year survival (hazard ratio, 2.97; 95% CI, 1.33-6.23), worse freedom from more than moderate MR (hazard ratio, 3.35; 95% CI, 1.60-7.00), and worse freedom from mitral reintervention (hazard ratio, 6.40; 95% CI, 2.19-18.72) (all P < .01).
Conclusions
A near 100% repair rate with acceptable durability may be achieved safely with intraoperative revision of postrepair residual MR. Mild residual MR was independently associated with reduced survival, worse freedom from more-than-moderate MR, and worse freedom from mitral reintervention at 8-year follow-up.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 05 Aug 2022; epub ahead of print
Chen Q, Roach A, Trento A, Rowe G, ... Bowdish ME, Chikwe J
J Thorac Cardiovasc Surg: 05 Aug 2022; epub ahead of print | PMID: 36182583
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Impact:
Abstract

National trends in the quality of segmentectomy for lung cancer.

Logan CD, Jacobs RC, Feinglass J, Lung K, ... Bharat A, Odell DD
Objective
Segmentectomy has become an accepted procedure for the treatment of non-small cell lung cancer. Adequate lymph node sampling, sufficient margins, and proper tumor size selection are factors vital for achieving outcomes comparable to lobectomy. Previous studies have demonstrated poor adherence to lymph node sampling guidelines. However, national trends in the quality of segmentectomy and implications on survival are unknown.
Methods
The National Cancer Database was used to identify patients with clinical stage I to IIA non-small cell lung cancer surgically treated between 2004 and 2018. Facility-level trends in extent of resection and segmentectomy odds of adherence to (1) 2014 Commission on Cancer guidelines of sampling 10 or more lymph nodes, (2) negative (R0) resection margins, and (3) tumor size 2 cm or less were determined. Propensity score matching was based on segmentectomy adherence to (4) a composite of all measures, and survival was evaluated with Cox models and Kaplan-Meier survival estimates.
Results
The study included 249,391 patients with 4.4% (n = 11,006) treated with segmentectomy. The proportion of segmentectomies performed annually increased from 3.3% in 2004 to 6.1% in 2018 (P < .001). Overall, 12.6% (n = 1385) of patients who underwent segmentectomy between 2004 and 2018 were adherent to all measures, and adherence was more likely at academic programs (odds ratio, 1.56; 95% confidence interval, 1.14-2.15) than nonacademic programs (P < .001, reference). Adherence to all measures was associated with improved survival (hazard ratio, 0.67; 95% confidence interval, 0.56-0.79).
Conclusions
As segmentectomy is increasingly established as a valid oncological option for the treatment of non-small cell lung cancer, it is important that quality remains high. This study demonstrates that continued improvement is needed.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 05 Aug 2022; epub ahead of print
Logan CD, Jacobs RC, Feinglass J, Lung K, ... Bharat A, Odell DD
J Thorac Cardiovasc Surg: 05 Aug 2022; epub ahead of print | PMID: 36088143
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Impact:
Abstract

Long-term outcomes of staged repair of tetralogy of Fallot.

Ye XT, Buratto E, Schulz A, Macalister SJ, ... Brizard CP, Konstantinov IE
Background
The optimal management strategy for symptomatic young infants with tetralogy of Fallot (TOF) is yet to be determined. We aimed to evaluate the long-term outcomes of a staged approach with initial shunt palliation followed by complete repair.
Methods
Between January 1993 and July 2021, 160 children with TOF underwent a systemic-to-pulmonary shunt at our institution, including 65 neonates (41%). The mean duration of follow-up was 12.3 ± 8.1 years.
Results
Hospital mortality was 3% (4 of 160), all occurring in patients with a shunt size-to-weight ratio ≥1.2 mm/kg. Composite morbidity-defined as cardiac arrest, postoperative mechanical circulatory support, or unplanned reoperation-occurred in 21% (33 of 160). On multivariable analysis, a shunt size-to-weight ratio ≥1.2 mm/kg and prematurity were independent predictors of composite morbidity. Interstage mortality was 3% (4 of 156). A limited transannular patch was used in 75% (113 of 150) of TOF repairs. Actuarial survival at 20 years after shunt was 90% (95% confidence interval [CI], 79%-95%). Actuarial freedom from reinterventions at 20 years after TOF repair was 40% (95% CI, 28%-52%). Neonates had comparable composite morbidity, mortality, and late risk of reinterventions to older children.
Conclusions
Staged repair of TOF in symptomatic young infants results in low mortality but high rates of reinterventions at long-term follow-up. A shunt size-to-weight ratio ≥1.2 mm/kg is a significant risk factor for mortality and morbidity prior to complete repair. Neonates undergoing shunt insertion have comparable outcomes to older children.

Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 05 Aug 2022; epub ahead of print
Ye XT, Buratto E, Schulz A, Macalister SJ, ... Brizard CP, Konstantinov IE
J Thorac Cardiovasc Surg: 05 Aug 2022; epub ahead of print | PMID: 36116957
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Impact:
Abstract

Extracellular vesicles modulate inflammatory signaling in chronically ischemic myocardium of swine with metabolic syndrome.

Sabe SA, Scrimgeour LA, Karbasiafshar C, Sabra M, ... Abid MR, Sellke FW
Objective
Extracellular vesicle (EV) therapy has been shown to mitigate inflammation in animal models of acute myocardial ischemia/reperfusion. This study evaluates the effect of EV therapy on inflammatory signaling in a porcine model of chronic myocardial ischemia and metabolic syndrome.
Methods
Yorkshire swine were fed a high-cholesterol diet for 4 weeks to induce metabolic syndrome, then underwent placement of an ameroid constrictor to the left circumflex artery to induce chronic myocardial ischemia. Two weeks later, pigs received intramyocardial injection of either saline (control) (n = 6) or EVs (n = 8). Five weeks later, pigs were put to death and left ventricular myocardial tissue in ischemic and nonischemic territories were harvested. Protein expression was measured with immunoblotting, and macrophage count was determined by immunofluorescent staining of cluster of differentiation 68. Data were statistically analyzed via Wilcoxon rank-sum test.
Results
EV treatment was associated with decreased expression of proinflammatory markers nuclear factor kappa B (P = .002), pro-interleukin (IL) 1ß (P = .020), and cluster of differentiation 11c (P = .001) in ischemic myocardium, and decreased expression of nuclear factor kappa B in nonischemic myocardium (P = .03) compared with control. EV treatment was associated with increased expression of anti-inflammatory markers IL-10 (P = .020) and cluster of differentiation 163 (P = .043) in ischemic myocardium compared with control. There were no significant differences in expression of IL-6, tumor necrosis factor alpha, arginase, HLA class II histocompatibility antigen DR alpha chain, nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor alpha, or phosphorylated nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor alpha in ischemic myocardium or pro-IL1ß, IL-6, tumor necrosis factor alpha, IL-10, or nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor alpha in nonischemic myocardium of EV-treated pigs compared with control. There were no differences in macrophage count in ischemic myocardium between EV-treated pigs and control.
Conclusions
In the setting of metabolic syndrome and chronic myocardial ischemia, intramyocardial EV therapy attenuates proinflammatory signaling.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Aug 2022; epub ahead of print
Sabe SA, Scrimgeour LA, Karbasiafshar C, Sabra M, ... Abid MR, Sellke FW
J Thorac Cardiovasc Surg: 04 Aug 2022; epub ahead of print | PMID: 36028364
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Impact:
Abstract

Poorly controlled hypertension is associated with increased coronary myogenic tone in patients undergoing cardiac surgery with cardiopulmonary bypass.

Sabe SA, Kononov MA, Bellam KG, Sodha N, ... Feng J, Sellke FW
Objective
Cardioplegia and cardiopulmonary bypass dysregulate coronary vasomotor tone, which can be further affected by common comorbidities in patients undergoing cardiac surgery. This study investigates differences in coronary myogenic tone and vasomotor responses to phenylephrine before and after cardioplegia and cardiopulmonary bypass based on hypertension history.
Methods
Coronary arterioles before and after cardioplegia and cardiopulmonary bypass were dissected from atrial tissue samples in patients with no hypertension, well-controlled hypertension, or uncontrolled hypertension, as determined by documented history of hypertension, antihypertensive agent use, and clinical blood pressure measurements averaged over 1 year. Myogenic tone in response to stepwise increases in intraluminal pressure was studied between pressure steps. Microvascular reactivity in response to phenylephrine was assessed via vessel myography. Protein expression was measured with immunoblotting.
Results
Coronary myogenic tone was significantly increased in the uncontrolled hypertension group compared with the no hypertension and well-controlled hypertension groups before cardioplegia and cardiopulmonary bypass at higher intraluminal pressures, and after cardioplegia and cardiopulmonary bypass across all intraluminal pressures (P < .05). Contractile responses to phenylephrine were significantly enhanced in patients in the uncontrolled hypertension group compared with the well-controlled hypertension group before cardioplegia and cardiopulmonary bypass, and in the uncontrolled hypertension group compared with the no hypertension and well-controlled hyertension groups after cardioplegia and cardiopulmonary bypass (P < .05). There were no differences in myogenic tone or phenylephrine-induced reactivity between the no hypertension and well-controlled hypertension groups (P > .05). There was increased expression of phosphorylated protein kinase C alpha in the uncontrolled hypertension group after cardiopulmonary bypass compared with before cardiopulmonary bypass and increased phosphorylated extracellular signal-regulated kinase 1/2 in the uncontrolled hypertension compared with the no hypertension group after cardiopulmonary bypass (P < .05).
Conclusions
Uncontrolled hypertension is associated with increased coronary myogenic tone and vasoconstrictive response to phenylephrine that persists after cardioplegia and cardiopulmonary bypass.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 02 Aug 2022; epub ahead of print
Sabe SA, Kononov MA, Bellam KG, Sodha N, ... Feng J, Sellke FW
J Thorac Cardiovasc Surg: 02 Aug 2022; epub ahead of print | PMID: 36008180
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Impact:
Abstract

Implementation of a non-intensive-care unit medical emergency team improves failure to rescue rates in cardiac surgery patients.

Young AM, Strobel RJ, Rotar E, Norman A, ... Brady W, Teman NR
Objective
Failure to rescue (FTR) is an emerging measure in cardiac surgery, defined as mortality after a postoperative complication. We hypothesized that establishing a medical emergency team (MET) reduced rates of FTR in adults undergoing cardiac surgery.
Methods
All patients (N = 11,218) undergoing a The Society of Thoracic Surgeons index operation at our center (1994-2018) were stratified by pre-MET or MET era based on the 2009 institutional implementation of a MET to respond to clinical decompensation in non-intensive-care patients. Patients missing The Society of Thoracic Surgeons predicted risk of mortality were excluded from all cohorts. Risk adjusted multivariable regression analyzed the association of postoperative complications, operative mortality, and FTR by era. Nearest neighbor propensity score matching utilizing patients\' The Society of Thoracic Surgeons predicted risk of mortality was performed to create balanced control and exposure groups for secondary subgroup analysis.
Results
In the risk-adjusted multivariable analysis, surgery during the MET era was associated with decreased mortality (odds ratio [OR], 0.51; 95% CI, 0.45-0.77; P < .001), postoperative renal failure (OR, 0.57; 95% CI, 0.46-0.70; P < .001), reoperation (OR, 0.75; 95% CI, 0.59-0.95; P = .017), and deep sternal wound infection (OR, 0.16; 95% CI, 0.04-0.45; P = .002). Surgery performed during the MET era was associated with a decreased rate of FTR in the risk-adjusted analysis (OR, 0.46; 95% CI, 0.34-0.70; P < .001).
Conclusions
The development of an institutional MET program was associated with a decrease in major complications and FTR. These findings support the development of MET programs to improve FTR after cardiac surgery.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 31 Jul 2022; epub ahead of print
Young AM, Strobel RJ, Rotar E, Norman A, ... Brady W, Teman NR
J Thorac Cardiovasc Surg: 31 Jul 2022; epub ahead of print | PMID: 36038381
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Impact:
Abstract

Socioeconomic distress is associated with failure to rescue in cardiac surgery.

Strobel RJ, Kaplan EF, Young AM, Rotar EP, ... Teman NR, Investigators for the Virginia Cardiac Services Quality Initiative
Objective
The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue.
Methods
Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue.
Results
A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044).
Conclusions
Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Jul 2022; epub ahead of print
Strobel RJ, Kaplan EF, Young AM, Rotar EP, ... Teman NR, Investigators for the Virginia Cardiac Services Quality Initiative
J Thorac Cardiovasc Surg: 20 Jul 2022; epub ahead of print | PMID: 36031426
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Impact:
Abstract

Aortic root translocation and en bloc rotation of the outflow tracts surgery for complex forms of transposition of the great arteries and double outlet right ventricle: A multicenter study.

Stoica S, Kreuzer M, Dorobantu DM, Kostolny M, ... Mair R, Hazekamp M
Objective
There are several choices for the correction of complex transposition of the great arteries and double outlet right ventricle not amenable to the Rastelli-type surgery, but outcome data are limited to small series. This study aims to report results after the aortic root translocation and en bloc rotation of the outflow tract procedures.
Methods
This is a retrospective, multicentric, observational study. Clinical, anatomy, procedural, and detailed follow-up data (median, 4.43 years) were collected.
Results
A total of 70 patients (62.9% male; median age, 1 year; range 4 days to 12.4 years) were included: n = 43 in the aortic root translocation group and n = 27 in the en bloc rotation group. Those in the aortic root translocation group were older (P = .01) and more likely to have had previous procedures (P < .0001), but cardiac anatomy was similar in both groups. Aortic root translocation and en bloc rotation early mortality (30 days) was similar (4.7% vs 3.7%, P = .8). Late survival and freedom from any cardiac reintervention were 92.7% and 16.9% at 15 years overall, respectively. Freedom from right ventricular outflow tract/conduit reintervention was better in the en bloc rotation group than in the aortic root translocation group (100% vs 24.5%, P = .0003), but more patients in the en bloc rotation group had moderate (or worse) aortic valve regurgitation during follow-up (16% vs 2.6%, P = .07).
Conclusions
Both aortic root translocation and en bloc rotation are valuable surgical options for the treatment of complex transposition of the great arteries and double outlet right ventricle. In the en bloc rotation group, there was better freedom from right ventricular outflow tract reinterventions, but a higher probability of aortic valve regurgitation. Identifying the main driving forces for these observed differences requires further study of these procedures.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Jul 2022; epub ahead of print
Stoica S, Kreuzer M, Dorobantu DM, Kostolny M, ... Mair R, Hazekamp M
J Thorac Cardiovasc Surg: 20 Jul 2022; epub ahead of print | PMID: 36028361
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Impact:
Abstract

Machine learning-based radiomic computed tomography phenotyping of thymic epithelial tumors: Predicting pathological and survival outcomes.

Tian D, Yan HJ, Shiiya H, Sato M, Shinozaki-Ushiku A, Nakajima J
Objective
For patients with thymic epithelial tumors, accurately predicting clinicopathological outcomes remains challenging. We aimed to investigate the performance of machine learning-based radiomic computed tomography phenotyping for predicting pathological (World Health Organization [WHO] type and TNM stage) and survival outcomes (overall and progression-free survival) in patients with thymic epithelial tumors.
Methods
This retrospective study included patients with thymic epithelial tumors between January 2001 and January 2022. The radiomic features were extracted from preoperative unenhanced computed tomography images. After strict feature selection, random forest and random survival forest models were fitted to predict pathological and survival outcomes, respectively. The model performance was assessed by the area under the curve (AUC) and validated internally by the bootstrap method.
Results
In total, 124 patients with a median age of 61 years were included. The radiomics random forest models of WHO type and TNM stage showed satisfactory performance with an AUCWHO of 0.898 (95% CI, 0.753-1.000) and an AUCTNM of 0.766 (95% CI, 0.642-0.886). For overall survival and progression-free survival prediction, the radiomics random survival forest models showed good performance (integrated AUCs, 0.923; 95% CI, 0.691-1.000 and 0.702; 95% CI, 0.513-0.875, respectively), and the integrated AUCs increased to 0.935 (95% CI, 0.705-1.000) and 0.811 (95% CI, 0.647-0.942), respectively, when combined with clinicopathological features.
Conclusions
Machine learning-based radiomic computed tomography phenotyping might allow for the satisfactory prediction of pathological and survival outcomes and further improve prognostic performance when integrated with clinicopathological features in patients with thymic epithelial tumors.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Jul 2022; epub ahead of print
Tian D, Yan HJ, Shiiya H, Sato M, Shinozaki-Ushiku A, Nakajima J
J Thorac Cardiovasc Surg: 20 Jul 2022; epub ahead of print | PMID: 36038386
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Abstract

Association between improved compliance with enhanced recovery after cardiac surgery guidelines and postoperative outcomes: A retrospective study.

Hoogma DF, Croonen R, Al Tmimi L, Tournoy J, ... Fieuws S, Rex S
Objective
Enhanced recovery after cardiac surgery is a multidisciplinary clinical care pathway that relies on a bundle of interventions, aiming to reduce the stress response to surgery and promote early recovery of organ function. In 2011, our institution introduced an institutional enhanced recovery after cardiac surgery program focusing on 9 central interventions, which have been expanded during the past decade by additional interventions now considered standard of care. After the recent publication of the enhanced recovery after cardiac surgery guidelines, we evaluated the relation between the compliance with these enhanced recovery after cardiac surgery guidelines and postoperative outcomes.
Methods
All patients enrolled in our enhanced recovery after cardiac surgery program in 2019 were included in this retrospective single-center audit. The primary outcome was compliance with 23 enhanced recovery after cardiac surgery guidelines. Secondary outcomes included occurrence of at least 1 postoperative complication and hospital length of stay.
Results
A total of 356 patients were included in this study. Compliance with the enhanced recovery after cardiac surgery guidelines was 64%. Postoperatively, 51% of the patients experienced at least 1 complication and had a median hospital length of stay of 6 days. Multivariable analysis showed that an increased compliance (per 10%) with the enhanced recovery after cardiac surgery guidelines was associated with a lower risk for any complication (odds ratio, 0.60; 95% confidence interval, 0.46-0.79; P = .0003) and a higher probability of earlier hospital discharge (hazard ratio, 1.25; 95% confidence interval, 1.10-1.43; P = .0008).
Conclusions
This audit revealed a correlation between increased compliance with enhanced recovery after cardiac surgery guidelines and a reduction of postoperative complications and hospital length of stay. Future trials are needed to establish evidence-based recommendations for each separate intervention of the enhanced recovery after cardiac surgery guidelines and to create a minimum core-set of enhanced recovery after cardiac surgery interventions.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 19 Jul 2022; epub ahead of print
Hoogma DF, Croonen R, Al Tmimi L, Tournoy J, ... Fieuws S, Rex S
J Thorac Cardiovasc Surg: 19 Jul 2022; epub ahead of print | PMID: 35989120
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Abstract

Operative management of cardiac papillary fibroelastomas.

Mazur P, Kurmann R, Klarich KW, Dearani JA, ... Maleszewski JJ, Crestanello JA
Objective
Papillary fibroelastomas are associated with an increased risk of embolic strokes. Excision of papillary fibroelastomas may be the primary indication for surgery (primary) or performed during other cardiac operations (secondary). The present study summarizes our experience with primary and secondary fibroelastoma surgery.
Methods
We analyzed the medical records of patients who underwent surgical excision of papillary fibroelastoma between January 1998 and February 2020. Patient characteristics, indications for operation, tumor size and location, and operative and long-term outcomes were evaluated.
Results
Among the 294 patients (median age: 66 years, 62% female), papillary fibroelastoma was the primary indication for surgery in 136 patients (46%), and 51% of patients had a history of stroke or transient ischemic attack. When papillary fibroelastoma was a secondary indication for surgery (158 patients, 54%), the lesion was identified preoperatively in 39%. Papillary fibroelastomas were located most commonly on the aortic valve and least commonly in the right side of the heart. For valvular papillary fibroelastoma resected from a normal valve, valve shave was sufficient in 96% (196/205). Operative mortality was low in both groups (primary, 0% vs secondary, 2.5%, P = .13), and early neurologic events occurred in 1.3%. Recurrence rate was 15.8% at 10 years. The estimated survival for patients with primary papillary fibroelastoma at 10 years was 78.4%, whereas for secondary papillary fibroelastoma removal it was 53.6% (log rank, P = .003).
Conclusions
Resection of papillary fibroelastomas can be performed safely, with preservation of the native valve, and with low rates of neurologic events. Operative and long-term outcomes after fibroelastoma resection are excellent.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print
Mazur P, Kurmann R, Klarich KW, Dearani JA, ... Maleszewski JJ, Crestanello JA
J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print | PMID: 35989118
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Abstract

The impact of prolonged mechanical ventilation after acute type A aortic dissection repair.

Diaz-Castrillon CE, Brown JA, Navid F, Serna-Gallegos D, ... Zhu J, Sultan I
Objective
Patients with type A aortic dissection have increased resource use. The objective of this study was to describe the relationship between prolonged mechanical ventilation and longitudinal survival in patients undergoing type A aortic dissection repair.
Methods
We conducted a retrospective analysis of patients with type A aortic dissection undergoing repair from 2010 to 2018; Kaplan-Meier function and adjusted Cox regression analysis were used to compare in-hospital mortality and longitudinal survival accounting for time on mechanical ventilatory support.
Results
A total of 552 patients were included. The study population was divided into 12 hours or less (n = 291), more than 12 to 24 or less hours (n = 101), more than 24 to 48 hours or less (n = 60), and more than 48 hours (n = 100) groups. Patients within the 12 or less hours group were the youngest (60.0 vs 63.5 years vs 63.6 vs 62.8 years; P = .03) and less likely to be female (31.6% vs 43.6% vs 46.7% vs 56.0%; P < .001). On the other hand, the more than 48 hours group presented with malperfusion syndrome at admission more often (24.4% vs 29.7% vs 28.3% vs 53.0%; P < .001) and had longer cardiopulmonary and ischemic times (P < .05). In-hospital mortality was significantly higher in the more than 48 hours group (5.2% vs 6.9% vs 3.3% vs 30.0%; P < .001). Multivariable analysis demonstrated worse longitudinal survival for the 24 to 48 hours group (hazard ratio, 1.94, confidence interval, 1.10-3.43) and more than 48 hours ventilation group (hazard ratio, 2.25, confidence interval, 1.30-3.92).
Conclusions
The need for prolonged mechanical ventilatory support is prevalent and associated with other perioperative complications. More important, after adjusting for other covariates, prolonged mechanical ventilation is an independent factor associated with increased longitudinal mortality.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print
Diaz-Castrillon CE, Brown JA, Navid F, Serna-Gallegos D, ... Zhu J, Sultan I
J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print | PMID: 35989122
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Abstract

Central versus peripheral cannulation for acute type A aortic dissection.

Yousef S, Brown JA, Serna-Gallegos D, Navid F, ... Diaz-Castrillon CE, Sultan I
Objective
This study sought to evaluate the impact of central aortic versus peripheral cannulation on outcomes after acute type A aortic dissection repair.
Methods
This was an observational study using an institutional database of acute type A aortic dissection repairs from 2007 to 2021. Patients were stratified according to central, subclavian, or femoral cannulation. Kaplan-Meier survival estimation and multivariable Cox regression were performed.
Results
The study population consisted of 577 patients who underwent acute type A aortic dissection repair. Of these, central cannulation was used in 490 patients (84.9%), subclavian cannulation was used in 54 patients (9.4%), and femoral cannulation was used in 33 patients (5.7%). Rates of peripheral vascular disease, aortic insufficiency moderate or greater, and cerebral malperfusion differed significantly among the groups, but baseline characteristics were otherwise comparable (P > .05). Operative mortality was lowest in the central cannulation group (9.8%), but this did not differ significantly among the groups. Kaplan-Meier survival estimates were similar among the groups. On multivariable Cox regression, cannulation strategy was not significantly associated with long-term survival.
Conclusions
Acute type A aortic dissection repair can be safely performed through central aortic cannulation, with outcomes comparable to those obtained with subclavian or femoral cannulation.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print
Yousef S, Brown JA, Serna-Gallegos D, Navid F, ... Diaz-Castrillon CE, Sultan I
J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print | PMID: 35989125
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Abstract

Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes.

Yang B, Ghita C, Makkinejad A, Green C, Wu X
Objective
To evaluate the safety and efficacy of a novel aortic annular enlargement technique.
Methods
From August 2020 to February 2022, 50 consecutive cases of aortic valve replacement with Y-incision aortic annular enlargement and other combined cardiac procedures were performed primarily for severe aortic stenosis. Data were obtained through medical record review, The Society of Thoracic Surgeons database, and National Death Index data.
Results
The median age was 65 (59, 71) years, 70% of patients were female, and 26% had previous cardiac surgery. Sixty-six percent patients had isolated aortic valve replacement. The preoperative mean gradient was 40 (30, 47) mm Hg, and the native aortic annular size was 21 (19, 23) mm. After aortic annular enlargement, the median prosthesis size was 27 (27, 29) with 54% of patients having a size 29 or the largest sized valve. The median increment of annulus enlargement was 3 (3, 4) valve sizes. 88% of patients received no blood transfusion. There were no major postoperative complications, including operative mortality, renal failure requiring permanent dialysis, mediastinitis, or reoperation for bleeding, except for 1 stroke. Three-month postoperative computed tomography aortogram showed the aortic root was enlarged from 27 (24, 30) to 40 (36, 41) mm without aortic pseudoaneurysm. The postoperative mean gradient was 7 (5, 8) mm Hg and valve area was 1.9 (1.7, 2.3) cm2 at 3 to 12 months. Mitral and tricuspid valve functions were significantly improved. Survival was 100% at 18 months.
Conclusions
Y-incision aortic annular enlargement was safe and effective for upsizing the aortic annulus by 3 to 4 valve sizes.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print
Yang B, Ghita C, Makkinejad A, Green C, Wu X
J Thorac Cardiovasc Surg: 16 Jul 2022; epub ahead of print | PMID: 36031424
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Abstract

Preservation versus replacement of the aortic root for acute type A aortic dissection.

Brown JA, Zhu J, Navid F, Serna-Gallegos D, ... Aranda-Michel E, Sultan I
Objective
To determine the impact of aortic root preservation versus aortic root replacement (ARR) after acute type A aortic dissection (ATAAD) repair.
Methods
In this observational study of consecutive aortic surgeries between 2007 and 2021, patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by root preservation versus ARR (including valve-sparing and complete ARR). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed.
Results
Among the 601 patients underwent aortic arch reconstruction for ATAAD, 370 (61.6%) underwent root preservation and the other 231 (38.4%) underwent ARR, with a median follow-up of 6.3 years (interquartile range, 3.8-9.6 years). Cardiopulmonary bypass and ischemic times were longer in the ARR group, but intraoperative variables were otherwise similar between the groups, including cannulation strategy and extent of distal repair. There were no between-group differences in postoperative outcomes, including operative mortality, stroke, mechanical ventilation time, renal failure, reexploration for bleeding, and total length of stay. At a 1-year follow-up, the incidence of aortic regurgitation (moderate or greater) was similar in the 2 groups. On multivariable Cox regression, ARR was not associated with improved long-term survival compared with root preservation (hazard ratio, 1.13; 95% confidence interval, 0.82-1.56; P = .44). Late reinterventions on the aortic root or valve were similar in the 2 groups and was 2.0% for the overall cohort.
Conclusions
These findings suggest that aortic root preservation may achieve similar midterm outcomes as ARR after ATAAD repair.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 14 Jul 2022; epub ahead of print
Brown JA, Zhu J, Navid F, Serna-Gallegos D, ... Aranda-Michel E, Sultan I
J Thorac Cardiovasc Surg: 14 Jul 2022; epub ahead of print | PMID: 35989123
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Abstract

Outcomes of emergency surgery for acute type A aortic dissection complicated by malperfusion syndrome.

Brown JA, Aranda-Michel E, Navid F, Serna-Gallegos D, Thoma F, Sultan I
Objective
The study objective was to determine the impact of malperfusion syndrome on in-hospital mortality and midterm survival after emergency aortic arch reconstruction for acute type A aortic dissection.
Methods
This was an observational study of aortic surgeries from 2010 to 2018. All patients with acute type A aortic dissection undergoing open aortic arch reconstruction were included. Patients were dichotomized by the presence or absence of malperfusion syndrome and were analyzed for differences in short-term postoperative outcomes, including morbidity and in-hospital mortality. Kaplan-Meier survival estimation and multivariable Cox analysis were performed to identify variables associated with survival.
Results
A total of 467 patients undergoing aortic arch reconstruction for acute type A aortic dissection were identified, of whom 332 (71.1%) presented without malperfusion syndrome and 135 (28.9%) presented with malperfusion syndrome. Patients with malperfusion syndrome had higher in-hospital mortality (21.5% vs 5.7%) than patients without malperfusion syndrome. After multivariable adjustment, malperfusion syndrome was associated with worse survival (hazard ratio, 2.43, 95% confidence interval, 1.61-3.66, P < .001) compared with patients without malperfusion syndrome. The predicted risk of mortality increased as the number of malperfused vascular beds increased. Patients with coronary malperfusion syndrome and neuro-malperfusion syndrome had reduced survival compared with the rest of the cohort (P < .05).
Conclusions
Malperfusion syndrome is associated with higher in-hospital mortality and reduced survival for patients with acute type A aortic dissection, with the risk of mortality increasing as the number of malperfused vascular beds increases. Coronary malperfusion syndrome and neuro-malperfusion syndrome may represent a high-risk subgroup of patients presenting with acute type A aortic dissection complicated by malperfusion syndrome. Finally, malperfusion syndrome may benefit from immediate surgical intervention to restore true lumen perfusion, as opposed to operative delay.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 14 Jul 2022; epub ahead of print
Brown JA, Aranda-Michel E, Navid F, Serna-Gallegos D, Thoma F, Sultan I
J Thorac Cardiovasc Surg: 14 Jul 2022; epub ahead of print | PMID: 35989124
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Impact:
Abstract

Rapid growth of thoracic aortic aneurysm: Reality or myth?

Sonsino A, Ellauzi H, Ziganshin BA, Zafar MA, Elefteriades JA
Objectives
The American Association for Thoracic Surgery 2010 guidelines stipulate that rapid growth of the aorta (>3 mm/y) is an indication for prophylactic surgical intervention. Because of the many potential sources of error in aortic measurement (including measurement variability and comparison of noncorresponding segments), we explored whether rapid aortic growth was a reality or a falsehood.
Methods
Among 2781 patients with aortic disease who were treated over 3 decades, we examined aortic growth rate in 811 patients with at least 2 aortic images taken at least 2 years apart. We identified 42 ascending and 27 descending patients with putative rapid aortic growth. A team of experienced clinicians reread the source images.
Results
Among the 42 ascending patients with putative rapid aortic growth, rapid growth was confirmed in 12 and refuted in 11 (19 images nonretrievable). Among the 27 descending patients, rapid growth was confirmed in 6 and refuted in 4 (17 images nonretrievable). We calculated lower, middle, and highest possible rapid growth rates by prorating positivity rates for nonretrievable scans. Lowest, middle, and highest possible rates of rapid growth were 2.7%, 4.7%, and 6.9% for ascending aorta, and 1.6%, 4.3%, and 7.3% for descending aneurysms, respectively. Middle rates are considered most accurately reflective. Of the patients with confirmed rapid growth, 3 of 4 inoperable patients succumbed to their aorta. Twenty-three patients underwent prompt surgery, with 22 survivors. For the rapidly growing aortas, operative, pathologic, and genetic findings are reported.
Conclusions
Although not a falsehood, rapid growth is uncommon for the ascending and descending aorta. Many putative cases are reflective of measurement error. Attention to potential sources of measurement error is key. VIDEO ABSTRACT.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 12 Jul 2022; epub ahead of print
Sonsino A, Ellauzi H, Ziganshin BA, Zafar MA, Elefteriades JA
J Thorac Cardiovasc Surg: 12 Jul 2022; epub ahead of print | PMID: 36028356
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Abstract

Smaller rectus femoris size measured by ultrasound is associated with poorer outcomes after cardiac surgery.

Ben-Menachem E, Ashes C, Lepar G, Deacon J, ... Molan V, Watson A
Objective
We sought to evaluate the association of low rectus femoris cross-sectional area (RFCSA) with hospital length of stay and poorer outcomes in patients undergoing cardiac surgery.
Methods
A single right-leg RFCSA was measured with ultrasound preoperatively and baseline characteristics, clinical data, and outcomes recorded. Patients were categorized as low rectus femoris muscle size (lowRF) or normal rectus femoris muscle size (normalRF), if they were in the lowest quartile or not, respectively. All analyses were performed on both body surface area (BSA)- and sex-adjusted RFCSA.
Results
One hundred eight-four patients had a RFCSA measured with a mean of 5.01 cm2 (1.41 cm2), and range of 0.71 to 8.77 cm2. When analyzing the BSA-adjusted RFCSA, we found the lowRF group had a longer hospital stay, 11.0 days [7.0-16.3] versus 8.0 days [6.0-10.0] for the normalRF group (P < .001), and a greater proportion of extended hospital stay (≥18.5 days) of 19.6% compared with 6.2% (P = .010). When the RFCSA was adjusted for sex, the lowRF group had a greater length of hospital stay, 9.0 days [7.0-14.5] versus 8.0 days [6.0-11.0] (P = .049). In both the BSA- and sex-adjusted RFCSA, the lowRF group suffered greater morbidity and were more likely discharged to a destination other than home. In multivariate analyses adjusting for European System for Cardiac Operative Risk Evaluation II, BSA-adjusted lowRF but not sex-adjusted lowRF was independently associated with log-transformed hospital length of stay. LowRF was not independently associated with increased major morbidity and death for both BSA and sex-adjusted RFCSA.
Conclusions
Low RFCSA has a significant association with increased hospital length of stay, morbidity, and nonhome discharge in patients undergoing cardiac procedures.
Trial registry number
ACTRN12620000678998.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 11 Jul 2022; epub ahead of print
Ben-Menachem E, Ashes C, Lepar G, Deacon J, ... Molan V, Watson A
J Thorac Cardiovasc Surg: 11 Jul 2022; epub ahead of print | PMID: 35995604
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Impact:
Abstract

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes.

Patlolla SH, Saran N, Schaff HV, Crestanello J, ... Daly RC, Dearani JA
Objectives
There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes.
Methods
We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients.
Results
The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time.
Conclusions
Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Jul 2022; epub ahead of print
Patlolla SH, Saran N, Schaff HV, Crestanello J, ... Daly RC, Dearani JA
J Thorac Cardiovasc Surg: 08 Jul 2022; epub ahead of print | PMID: 36028365
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Impact:
Abstract

Should all patients receive extended thromboprophylaxis after resection of primary lung cancer?

Kho J, Mitchell J, Curry N, Di Chiara F, Stavroulias D, Belcher E
Objective
The optimal duration of thromboprophylaxis in patients undergoing resection of primary lung cancer is not known. We investigated the incidence of pulmonary emboli and venous thromboembolism in patients undergoing early-stage lung cancer resection and the impact of change from short duration to extended thromboprophylaxis.
Methods
We reviewed the outcomes of consecutive patients who underwent resection of early-stage primary lung cancer following a change in protocol from inpatient-only to extended thromboprophylaxis to 28 days. Propensity-score matching of control (routine inpatient pharmacologic thromboprophylaxis) and treatment group (extended pharmacologic thromboprophylaxis) was performed. Adjustment for covariates based on the Caprini risk assessment model was undertaken. Thromboembolic outcomes were compared between the 2 groups.
Results
Seven hundred fifty consecutive patients underwent resection of primary lung cancer at Oxford University Hospitals NHS Foundation Trust between January 2013 and December 2018. Six hundred patients were included for analysis and propensity-score matching resulted in 253 matched pairs. Extended prophylaxis was associated with a significant reduction in pulmonary emboli (10 of 253 patients [4%] vs 1 of 253 patients [0.4%], P = .01). One patient (0.4%) developed a bleeding complication within the treatment cohort. Multivariable logistic regression model demonstrated that extended thromboprophylaxis was independently associated with a reduction in postoperative pulmonary emboli.
Conclusions
Patients undergoing lung cancer resection surgery are at moderate-to-high risk of postoperative thromboembolic disease. Extended dalteparin for 28 days is safe and is associated with reduced incidence of pulmonary embolus in patients undergoing resection of early-stage primary lung cancer.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 05 Jul 2022; epub ahead of print
Kho J, Mitchell J, Curry N, Di Chiara F, Stavroulias D, Belcher E
J Thorac Cardiovasc Surg: 05 Jul 2022; epub ahead of print | PMID: 35953309
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Impact:
Abstract

Ten-year follow-up of lung cancer patients with resected adenocarcinoma in situ or minimally invasive adenocarcinoma: Wedge resection is curative.

Li D, Deng C, Wang S, Li Y, Zhang Y, Chen H
Objective
This study aimed to reveal the long-term outcomes of patients with lung cancer with adenocarcinoma in situ or minimally invasive adenocarcinoma after resection, in the context of the different surgical resection types.
Methods
Patients with lung adenocarcinoma who underwent resection between December 2007 and December 2012 were reviewed. Patients with pathological adenocarcinoma in situ or minimally invasive adenocarcinoma were enrolled. Postoperative survival and risk of developing second primary lung cancer were analyzed.
Results
After reevaluating the histological findings of 1696 patients with lung adenocarcinoma, we enrolled 53 with adenocarcinoma in situ and 72 with minimally invasive adenocarcinoma for analyses. Of all 125 patients with adenocarcinoma in situ/minimally invasive adenocarcinoma, 86 (68.8%) were female, 114 (91.2%) were nonsmokers, and most of them (78, 62.4%) underwent wedge resection. The median follow-up period after surgery was 111 months. The 10-year recurrence-free survivals of adenocarcinoma in situ and minimally invasive adenocarcinoma were all 100%, and the 10-year overall survivals of adenocarcinoma in situ and minimally invasive adenocarcinoma were 98.1% and 97.2%, respectively. There was no difference in 10-year recurrence-free survival between patients who underwent lobectomy and wedge resection. EGFR mutations were detected in 63.1% (41/65) of patients who underwent mutational analysis. The risks of developing second primary lung cancer for adenocarcinoma in situ and minimally invasive adenocarcinoma 10 years after resection were 8.4% and 4.3% (P = .298), respectively, and were not correlated with EGFR mutation status (P = .525).
Conclusions
Pathological adenocarcinoma in situ and minimally invasive adenocarcinoma have no recurrence during 10-year follow-up after resection, regardless of surgical procedure types. Surgery is curative for these patients, and wedge resection is the preferred surgical procedure for nodules in the proper location.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 05 Jul 2022; epub ahead of print
Li D, Deng C, Wang S, Li Y, Zhang Y, Chen H
J Thorac Cardiovasc Surg: 05 Jul 2022; epub ahead of print | PMID: 35965138
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Impact:

This program is still in alpha version.