Journal: J Thorac Cardiovasc Surg

Sorted by: date / impact
Abstract

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

Narahari AK, Cook IO, Mehaffey JH, Chandrabhatla AS, ... Roeser ME, Ailawadi G
Objective
To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands.
Methods
Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric.
Results
A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution\'s overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants.
Conclusions
NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Narahari AK, Cook IO, Mehaffey JH, Chandrabhatla AS, ... Roeser ME, Ailawadi G
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31604638
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Abstract

Abnormalities in cerebral hemodynamics and changes with surgical intervention in neonates with congenital heart disease.

Cheng HH, Ferradal SL, Vyas R, Wigmore D, ... Newburger JW, Grant PE
Objective
To use novel optical techniques to measure perioperative cerebral hemodynamics of diverse congenital heart disease (CHD) groups (two-ventricle, d-transposition of the great arteries [TGA], and single ventricle [SV]) and (1) compare CHD groups with healthy controls preoperatively and (2) compare preoperative and postoperative values within each CHD group.
Methods
Frequency-domain near-infrared spectroscopy and diffuse correlation spectroscopy were used to measure cerebral oxygen saturation, cerebral blood volume, cerebral blood flow index, cerebral oxygen extraction fraction (OEF, calculated using arterial oxygen saturation and cerebral oxygen saturation), and an index of cerebral metabolic rate of oxygen consumption in control and CHD neonates. Preoperative CHD measures were compared with controls. Preoperative and postoperative measures were compared within each CHD group.
Results
In total, 31 CHD neonates (7 two-ventricle, 11 TGA, 13 SV) and 13 controls were included. Only neonates with SV CHD displayed significantly lower preoperative cerebral blood flow index (P < .04) than controls. TGA and SV groups displayed greater OEF (P < .05) during the preoperative period compared with controls. Compared with the preoperative state, postoperative neonates with TGA had a greater arterial oxygen saturation with lower OEF.
Conclusions
Differences in cerebral hemodynamics and oxygen metabolism were observed in diverse CHD groups compared with controls. Increased OEF appears to be a compensatory mechanism in neonates with TGA and SV. Studies are needed to understand the relationship of these metrics to outcome and their potential to guide interventions to improve outcome.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 15 Sep 2019; epub ahead of print
Cheng HH, Ferradal SL, Vyas R, Wigmore D, ... Newburger JW, Grant PE
J Thorac Cardiovasc Surg: 15 Sep 2019; epub ahead of print | PMID: 31685276
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Abstract

Propensity-score adjusted comparison of pathologic nodal upstaging by robotic, video-assisted thoracoscopic, and open lobectomy for non-small cell lung cancer.

Kneuertz PJ, Cheufou DH, D\'Souza DM, Mardanzai K, ... Aigner C, Merritt RE
Objective
To assess the effectiveness of intraoperative lymph node (LN) staging by comparing upstaging between robotic-assisted surgery, video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach for lobectomy for non-small cell lung cancer.
Methods
We retrospectively analyzed 1053 patients with clinical stage N0/N1 non-small cell lung cancer who underwent lobectomy at 2 centers between 2011 and 2018. Propensity score adjustment by inverse probability of treatment weighting was used to balance baseline characteristics. The primary end point was LN upstaging.
Results
A total of 911 patients (254 robotic, 296 VATS, and 261 open) were included in the inverse probability of treatment weighting adjusted analysis. The overall rate of LN upstaging was highest with open lobectomy (21.8%), followed by robotic (16.2%), and VATS (12.3%) (P = .03). Mediastinal N2 upstaging was observed in similar frequencies (open 6.9% vs robotic 6.3% vs VATS 4.4%; P = .6). No differences were seen for total LN counts, but were observed in the number of stations sampled (mean, open 4.0 vs robotic 3.8 vs VATS 3.6; P = .001). On multivariate analysis, LN upstaging was lower for VATS compared with open (odds ratio, 0.50; 95% confidence interval, 0.29-0.85), but not different between robotic and open (odds ratio, 0.72; 95% confidence interval, 0.44-1.18). No significant differences were seen in mediastinal N2 upstaging between groups.
Conclusions
Pathologic LN upstaging following lobectomy for clinically N0/N1 NSCLC remains high. Compared with a traditional thoracotomy approach, robotic lobectomy was associated with similar and VATS with lower overall nodal upstaging. A thorough evaluation of hilar and mediastinal LNs remains critical to ensure accurate staging by detection of occult LN metastases.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 30 Oct 2019; 158:1457-1466.e2
Kneuertz PJ, Cheufou DH, D'Souza DM, Mardanzai K, ... Aigner C, Merritt RE
J Thorac Cardiovasc Surg: 30 Oct 2019; 158:1457-1466.e2 | PMID: 31623811
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Abstract

Noncardiac determinants of death and intensive care morbidity in adult congenital heart disease surgery.

Lei Lei E, Ladha K, Mueller B, Roche L, ... Hickey E, Heggie J
Objectives
Predicting perioperative morbidity and mortality in cardiac surgery for adult congenital heart disease is challenging because it encompasses a wide spectrum of disease. There is a paucity of published outcome data, and there are no perioperative risk score calculators for this population group. We set out to identify robust determinants of morbidity and mortality in this patient population under going cardiac surgery.
Methods
We collected data on 20 socioeconomic and pathophysiologic variables in 784 consecutive adults with congenital heart disease who underwent cardiac surgery between 2004 and 2015 at a single center. Using logistic regression, we sought to identify which of these factors were associated with the primary composite adverse outcome of in-hospital mortality, prolonged ventilation exceeding 7 days, and severe acute renal failure requiring dialysis. Secondary outcome analysis identified variables that were significant predictors for 1-year mortality.
Results
Composite adverse outcome occurred in 54 of 784 patients (6.9%). Significant predictors of the composite adverse outcome by multivariate regression include Mayo End-Stage Liver Disease modified score, cognitive impairment, number of chest wall incisions from previous cardiac surgery, body mass index, and cardiac anatomic category. Two survivors of the composite adverse outcome died within a few weeks postdischarge. Only 657 of 784 patients had 1-year follow-up data; 40 of 657 patients died at 1 year. One-year mortality was predicted by anticoagulation, Mayo End-Stage Liver Disease modified score, and anatomic category.
Conclusions
Recognition and quantification of noncardiac comorbidities preoperatively predict the risk of adverse events and mortality in addition to cardiac anatomic factors.

Copyright © 2019 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 28 Aug 2019; epub ahead of print
Lei Lei E, Ladha K, Mueller B, Roche L, ... Hickey E, Heggie J
J Thorac Cardiovasc Surg: 28 Aug 2019; epub ahead of print | PMID: 31585755
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Abstract

Prenatal hypoxemia alters microglial morphology in fetal sheep.

Lawrence KM, McGovern PE, Mejaddam A, Rossidis AC, ... Flake AW, Gaynor JW
Objective
Neuroimmune cells, particularly microglia and astrocytes, play a critical role in neurodevelopment. Neurocognitive delays are common in children with congenital heart disease, but their etiology is poorly understood. Our objective was to determine whether prenatal hypoxemia, at levels common in congenital heart disease, induced neuroimmune activation to better understand the origins of neurobehavioral disorders in congenital heart disease.
Methods
Eight fetal sheep at gestational age 109 ± 3 days (term ∼145 days) were cannulated onto a pumpless extracorporeal oxygenator via the umbilical vessels and supported in a fluid environment for 22 ± 2 days under normoxic (n = 4) or hypoxic (n = 4) conditions. Control fetuses (n = 7) were harvested at gestational age 133 ± 4 days. At necropsy, brains were stained with ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein antibodies to quantify microglia and astrocytes, respectively, in gray and white matter in frontotemporal and cerebellar sections. Microglia were classified into 4 morphologic types based on cell shape. Data were analyzed with 1-way analysis of variance or Fisher exact test, as appropriate.
Results
Oxygen delivery was significantly reduced in hypoxic fetuses (15.6 ± 1.8 mL/kg/min vs 24.3 ± 2.3 mL/kg/min; P < .01). Rates of apoptosis were similar in hypoxic, normoxic, and intrauterine control animals in all examined areas. There were also no differences between groups in area occupied by glial fibrillary acidic protein-labeled astrocytes or ionized calcium-binding adaptor molecule 1-labeled microglia in all examined areas. However, round microglia were significantly increased in hypoxic animals compared with normoxic animals (33% vs 6%; P < .01) and control animals (33% vs 11%; P < .01).
Conclusions
Prenatal hypoxemia altered microglial morphology without significant gliosis. Additional studies characterizing these mechanisms may provide insight into the origins of neurobehavioral disabilities in children with congenital heart disease.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Lawrence KM, McGovern PE, Mejaddam A, Rossidis AC, ... Flake AW, Gaynor JW
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31597618
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Abstract

Longitudinal functional health status in young adults with repaired dextro-transposition of the great arteries: A Congenital Heart Surgeons\' Society study.

Jegatheeswaran A, Devlin PJ, DeCampli WM, Welke KF, ... Woods RK, McCrindle BW
Objectives
Improved survival has led to interest in functional health status (FHS) as patients with dextro-transposition of the great arteries (d-TGA) transition to adulthood. Our primary objectives were (1) evaluation of The Medical Outcomes Study Short Form-36 Health Survey (SF-36) results; (2) comparison with results of patients who completed the Child Health Questionnaire-Child Form 87 (CHQ-CF87) previously, or the PedsQL Generic Core Scales (PedsQL) survey subsequently; and (3) determination of factors associated with SF-36 domains.
Methods
Survivors from the d-TGA Congenital Heart Surgeons\' Society cohort (1985-1989) completed the SF-36 (2010) as a measure of FHS (n = 210; age 21-26 years). Patient characteristics, medical history, psychosocial factors, and previous adolescent CHQ-CF87 FHS assessment (2000) were explored for association with SF-36 domains, along with comparison with recent PedsQL data (2017).
Results
Patients scored themselves the same/higher than published normative data in 10 of 10 SF-36 summary scores/domains and similar in 5 of 6 PedsQL summary scores/domains. Factors commonly associated with lower summary scores/domains of the SF-36 were presence of cardiac symptoms, heart condition impacting physical activity/overall health/quality of life, unemployment, and lack of postsecondary education. Less commonly associated factors were lower birth weight, greater total medication number, female sex, shorter procedure-free interval, poor health knowledge, lower family income, younger age at SF-36, living with parents, and being married. These factors accounted for 17% to 47% of the variation in FHS summary scores/domains. FHS was minimally related to d-TGA morphology and repair type.
Conclusions
Patients with d-TGA surviving into adulthood, regardless of morphology or repair type, can primarily expect normal FHS. Addressing the challenges of patients with d-TGA entering adulthood requires consideration of psychosocial factors and clinical management.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print
Jegatheeswaran A, Devlin PJ, DeCampli WM, Welke KF, ... Woods RK, McCrindle BW
J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print | PMID: 31677883
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Abstract

Outcomes of the arterial switch operation in patients with aortic arch obstruction.

Fricke TA, Donaldson S, Schneider JR, Menahem S, ... Brizard CP, Konstantinov IE
Objective
Transposition of the great arteries or Taussig-Bing anomaly with concomitant aortic arch obstruction is uncommon, with limited data on long-term outcomes after arterial switch operation and aortic arch obstruction repair. This study sought to determine outcomes of patients undergoing arterial switch operation and aortic arch obstruction repair at a single institution.
Methods
From 1983 to 2015, 844 patients underwent an arterial switch operation for biventricular repair at The Royal Children\'s Hospital. Eighty-three (9.8%, 83/844) patients underwent an arterial switch operation and aortic arch obstruction repair.
Results
Fifty-five (66%, 55/83) patients had transposition of the great arteries. and 28 (34%, 28/83) patients had Taussig-Bing anomaly. Fifty-nine (71%, 59/83) patients underwent arterial switch operation and aortic arch obstruction repair as a single-stage procedure, and 24 (29%, 24/83) patients underwent arterial switch operation and aortic arch obstruction repair as a 2-stage procedure. There were 5 early deaths (6.0%, 5/83). Follow-up was available for 74 (95%) of the 78 survivors. Median follow-up was 13.3 years (interquartile range, 7.3-19.3 years; range, 1-30 years). There were no late deaths. Freedom from reintervention was 77%, 71%, and 68% at 5, 10, and 20 years, respectively. Reintervention was more common compared with patients without aortic arch obstruction (P < .001). Reintervention for right-sided obstruction was more common compared with patients without aortic arch obstruction (P = .006).
Conclusions
Patients with transposition of the great arteries or Taussig-Bing anomaly with associated aortic arch obstruction have a higher reintervention rate, especially for right-sided obstruction. Closer monitoring of this subgroup of patients is warranted.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Fricke TA, Donaldson S, Schneider JR, Menahem S, ... Brizard CP, Konstantinov IE
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31607495
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Abstract

Safety, efficacy, and hemodynamic performance of a stented bovine pericardial aortic valve bioprosthesis: Two-year analysis.

Dagenais F, Moront MG, Brown WM, Reardon MJ, ... Gearhart E, Klautz RJM
Objectives
The study objectives were to evaluate the safety, efficacy, and hemodynamic performance of a novel stented bovine pericardial aortic valve bioprosthesis 2 years after implantation.
Methods
The PERIcardial SurGical AOrtic Valve ReplacemeNT Pivotal Trial enrolled patients with symptomatic moderate/severe aortic stenosis or regurgitation at centers in Canada, Europe, and the United States. We report the outcomes and hemodynamic performance in patients with up to 2 years of follow-up.
Results
A total of 1273 patients were enrolled, and 1110 underwent implantation. Among patients undergoing implantation, the mean age was 70.2 ± 8.9 years; 833 (75.0%) were male. Risk of mortality (Society of Thoracic Surgeons) was 2.0% ± 1.4%. At the time of analysis, 604 patients had completed the 2-year follow-up visit. Linearized late event rates were as follows: all death, 2.68%; valve-related death, 0.42%; valve thrombosis, 0.05%; endocarditis, 0.94%; thromboembolism, 1.68%; all hemorrhage, 2.94%; major hemorrhage, 1.99%; all paravalvular leak, 0.26%; and major paravalvular leak, 0.05% per patient-year. Mean 2-year aortic gradient and effective orifice area were 13.4 ± 5.0 mm Hg and 1.5 ± 0.37 cm, respectively. Moderate and severe prosthesis-patient mismatch were observed in 43.5% and 34.8% of patients at 2 years, respectively. Improvement in New York Heart Association class compared with baseline was observed in 73.0% with moderate mismatch and 74.1% with severe mismatch.
Conclusions
The Avalus (Medtronic, Minneapolis, Minn) bovine pericardial valve demonstrates good clinical and safety outcomes at 2 years. Hemodynamic performance shows mean gradients comparable to currently available bovine pericardial aortic valves. There was no clinical impact of moderate to severe mismatch at 2 years. Further follow-up is required to evaluate midterm to long-term clinical outcome.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Dagenais F, Moront MG, Brown WM, Reardon MJ, ... Gearhart E, Klautz RJM
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31590957
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Abstract

Management of the aortic arch in patients with Loeys-Dietz syndrome.

Schoenhoff FS, Alejo DE, Black JH, Crawford TC, ... Carrel TP, Cameron DE
Objectives
We sought to develop strategies for management of the aortic arch in patients with Loeys-Dietz syndrome (LDS) through a review of our clinical experience with these patients and a comparison with our experience in patients with Marfan syndrome (MFS).
Methods
We reviewed hospital and follow-up records of 79 patients with LDS and compared them with 256 patients with MFS who served as reference controls.
Results
In the LDS group, 16% of patients presented initially with acute aortic dissection (AAD) (67% type A, 33% type B) or developed AAD during follow-up, compared with 10% of patients with MFS (95% type A, 5% type B). There was no difference between patients with LDS or MFS in need for subsequent arch interventions after aortic root surgery (46% vs 50%, P = 1.0). Among the patients who never had AAD, the need for arch repair at initial root surgery was greater in patients with LDS (5% vs 0.4%, P = .04), as was the need for any subsequent aortic surgery (12% vs 1.3%, P = .0004). Late mortality in patients with LDS after arch repair was greater than in those patients who had no arch intervention (33% vs 6%, P = .007).
Conclusions
In the absence of dissection, patients with LDS have a greater rate of arch intervention after root surgery than patients with MFS. After a dissection, arch reintervention rates are similar in the 2 groups. Arch intervention portends greater late mortality in LDS.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Schoenhoff FS, Alejo DE, Black JH, Crawford TC, ... Carrel TP, Cameron DE
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31627951
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Abstract

Surgical ablation of atrial fibrillation concomitant to coronary-artery bypass grafting provides cost-effective mortality reduction.

Rankin JS, Lerner DJ, Braid-Forbes MJ, McCrea MM, Badhwar V
Background
Data on the longitudinal impact of surgical ablation (SA) for atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) remain limited. This study examined 2-year risk-adjusted mortality and total hospital costs in Medicare beneficiaries with AF requiring CABG with or without SA.
Methods
CABG was performed in 3745 Medicare beneficiaries with AF in 2013, with concomitant SA in 17% (626 of 3745). Risk-adjusted mortality, morbidity, and cost during the first 2 postoperative years for patients with SA and those without SA were compared. A piecewise Cox proportional hazard model (0-90 days and 91-729 days) was used to risk-adjust mortality.
Results
Compared with the no SA group, the SA group had lower rates of heart failure before surgery (31% vs 36%), chronic lung disease (27% vs 33%), renal failure (4% vs 7%), and urgent or emergent presentation (34% vs 49%) (all P < .05). Risk-adjusted index admission costs were higher with SA (rate ratio [RR], 1.11; P < .01), as were readmissions for AF (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.00-1.29; P = .04) and pacemaker/defibrillator implantation (HR, 1.37; 95%, 1.08-1.74; P = .01). Risk-adjusted inpatient days and inpatient costs were similar after 2 years (RR, 0.97; P = .31 and RR = 1.04; P = .17, respectively); however, the risk-adjusted hazard for late mortality (91-729 days) was significantly lower with SA (HR, 0.71; 95% CI, 0.52-0.97; P = .03).
Conclusions
In patients with AF requiring CABG, SA was associated with a 29% lower risk-adjusted hazard for late mortality. Index hospital costs were higher with SA, but total inpatient costs were not different in the 2 groups after 2 years. SA appears to be a cost-effective intervention to enhance late 2-year survival in patients with AF undergoing CABG.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Sep 2019; epub ahead of print
Rankin JS, Lerner DJ, Braid-Forbes MJ, McCrea MM, Badhwar V
J Thorac Cardiovasc Surg: 09 Sep 2019; epub ahead of print | PMID: 31610956
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Abstract

Cardiac surgery residents training in Germany-Status quo and future prospects.

Wick A, Beckmann A, Nemeth A, Conradi L, ... Reichenspurner H, Schlensak C

Residency training for specialization in cardiac surgery in Germany recently underwent a series of changes. A new 6-year integrated curriculum has been created that is based on acquisition of specific expertise rather than a rigid time frame. In effect, the training paradigm is one that is competency-based. After compliance with the curricular requirements and successfully completion of an examination, the Federal Medical Chamber grants the status of a licensed specialized physician (\"Facharzt\") and issues a certificate, which allows for independent clinical practice. There is no recertification during the course of the physicians\' professional career. The educational curricula for specialized training are issued by the National Medical Chamber in cooperation with the respective surgical societies and passed by the German Medical Assembly.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Wick A, Beckmann A, Nemeth A, Conradi L, ... Reichenspurner H, Schlensak C
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31669027
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Abstract

Survival after adjuvant radiation therapy in localized small cell lung cancer treated with complete resection.

Engelhardt KE, Coughlin JM, DeCamp MM, Denlinger CE, ... Bharat A, Odell DD
Objectives
To determine whether there is an overall survival (OS) benefit to the addition of thoracic radiation therapy (RT) following R0 resection of pathologic (p) T1 or pT2 N0 M0 small cell lung cancer.
Methods
Using the National Cancer Database, we performed a retrospective cohort analysis. Patients who underwent R0 resection for pT1 or p2 N0 M0 small cell lung cancer, stratified by receipt of adjuvant thoracic RT, were compared on the basis of OS using hierarchical Cox Proportional hazards models.
Results
Of 4969 patients diagnosed with pT1or pT2 N0 M0 SCLC from 2004 to 2014, 1617 (33%) underwent R0 resection of their primary tumor; of these resected patients, 146 (9.0%) had adjuvant thoracic RT. In unadjusted analysis, there was no significant difference in OS between groups (median survival: surgery alone, 62.2 months vs surgery+RT, 43.8 months; P = .1436). In multivariable analysis, RT was not associated with improved survival (P = .099). There was no significant difference in unadjusted or adjusted survival associated with receipt of RT in both a young and healthy cohort (P = .647 for unadjusted and P = .858 for adjusted) and a matched cohort (P = .867 and P = .954). In the matched cohort, improved OS was associated with younger patient age (adjusted hazard ratio, 1.07; 95% confidence interval, 1.04-1.10; P < .001), female sex (adjusted hazard ratio, 0.68, 95% confidence interval, 0.47-0.97; P = .035), and smaller tumors (adjusted hazard ratio, 1.02; 95% confidence interval, 1.01-1.03; P = .005). Having 2 or more comorbidities was associated with worse OS (adjusted hazard ratio, 2.16; 95% confidence interval, 1.21-3.86; P = .009).
Conclusions
Although complete resection was accomplished in a minority of patients, for these patients, survival was good. The addition of thoracic RT to complete resection does not appear to confer additional survival benefit.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Engelhardt KE, Coughlin JM, DeCamp MM, Denlinger CE, ... Bharat A, Odell DD
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31627955
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Abstract

Normothermic ex vivo lung perfusion: Does the indication impact organ utilization and patient outcomes after transplantation?

Cypel M, Yeung JC, Donahoe L, Chen M, ... Waddell TK, Keshavjee S
Background
Ex vivo lung perfusion (EVLP) is being increasingly applied as a method to evaluate and treat donor lungs for transplantation. However, with the previous limited worldwide experience, no studies have been able to evaluate the impact of indication for EVLP on organ utilization rates and recipient outcomes after lung transplantation (LTx). We examined these outcomes in a large-cohort, single-center series of clinical EVLP cases.
Methods
All EVLP procedures performed at our institution between October 2008 and December 2017 were examined. The EVLPs were divided into 4 groups based on the indication for the procedure: group 1, high-risk brain death donors (HR-BDD); group 2, standard-risk donation after cardiac death (S-DCD); group 3, high-risk donation after cardiac death (HR-DCD); and group 4, logistics (LOGISTICS, the need for prolongation of preservation time or organ retrieval by a different transplantation team).
Results
During the study period, a total of 1106 lung transplants were performed in our institution. In this period, 372 EVLPs were performed, 255 (69%) of which were accepted for transplantation, resulting in 262 transplants. Utilization rates were 70% (140 of 198) for group 1, 82% (40 of 49) for group 2, 63% (69 of 109) for group 3, and 81% (13 of 16) for group 4 (P = .42, Fisher\'s exact test). Recipient age (P = .27) and medical diagnosis (P = .31) were not different across the 4 groups. Kaplan-Meier survival by EVLP indication group demonstrated no differences. Thirty-day mortality was 2.1% in group 1, 5% in group 2, 2.9% in group 3, and 0% in group 4 (P = .87, Fisher\'s exact test). The median days of mechanical ventilation, intensive care unit stay, and hospital stay were 2, 4, and 21 in group 1; 2, 3, and 21 in group 2; 3, 5, and 28 in group 3; and 2, 4, and 17 in group 4 (P = .29, .17, and .09, respectively, Kruskal-Wallis rank-sum test).
Conclusions
Clinical implementation of EVLP has allowed our program to expand the annual lung transplantation activity by 70% in this time period. It has improved confidence in the utilization of DCD lungs and BDD lungs, with an average 70% utilization of post-EVLP treated donor lungs with excellent outcomes, while addressing significant challenges in donor lung assessment and the logistics of \"real-life\" clinical lung transplantation.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Cypel M, Yeung JC, Donahoe L, Chen M, ... Waddell TK, Keshavjee S
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31606173
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Impact:
Abstract

Outcomes of surgery versus chemoradiotherapy in patients with clinical or pathologic stage N3 non-small cell lung cancer.

Raman V, Jawitz OK, Yang CJ, Voigt SL, ... Harpole DH, Tong BC
Background
Because surgery is rarely recommended, there is minimal literature comparing the outcomes of surgery and chemoradiation in stage N3 non-small cell lung cancer (NSCLC). We examined the outcomes of definitive chemoradiation versus multimodality therapy, including surgery, for patients with clinical and pathologic stage N3 NSCLC.
Methods
The National Cancer Database was used to identify patients with clinical stage T1 to T3 N3 M0 NSCLC and clinical stage T1 to T3 Nx M0 with pathologic stage N3 NSCLC who were treated with either definitive chemoradiation or surgery between 2004-2015. A 1:1 propensity score-matched analysis was used to compare outcomes for both treatment groups in each analysis. The primary outcome was overall survival.
Results
In 935 matched patient pairs with clinical stage N3 NSCLC, surgery was associated with worse survival (hazard ratio, 1.52; 95% confidence interval, 1.12-2.05) compared with chemoradiation at 6 months, but was associated with a significant survival benefit after 6 months (hazard ratio, 0.54; confidence interval, 0.47-0.63) in multivariable analysis. In 281 pairs of patients with pN3 NSCLC, surgery had similar survival compared with chemoradiation at 6 months (hazard ratio, 1.71; 95% confidence interval, 0.92-3.19), but was associated with improved survival after 6 months (hazard ratio, 0.76; 95% confidence interval, 0.58-0.99). The complete resection rate was 80% and 73% for patients with clinical stage N3 and pathologic stage N3 disease, respectively.
Conclusions
In patients with clinical or pathologic stage N3 NSCLC, surgery is associated with similar or worse short-term but improved long-term survival compared with chemoradiation. In a selected group of patients with stage N3 NSCLC, surgery may have a role in multimodal therapy.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Raman V, Jawitz OK, Yang CJ, Voigt SL, ... Harpole DH, Tong BC
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31606169
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Impact:
Abstract

Is incidental splenectomy during thoracoabdominal aortic aneurysm repair associated with reduced survival?

Chatterjee S, LeMaire SA, Green SY, Price MD, ... Todd SR, Coselli JS
Objective
The effect of incidental splenectomy during thoracoabdominal aortic aneurysm repair is unknown. We hypothesized incidental splenectomy was associated with decreased late survival.
Methods
We studied 1056 thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Exclusion criteria were age less than 18 years (n = 9), prior splenectomy (n = 2), and intraoperative death (n = 3). This left 1042 thoracoabdominal aortic aneurysm repairs for analysis (median age, 65 years; interquartile range, 56-72), including 221 (21%) that were reoperations. Multivariable modeling identified predictors of operative mortality in the total cohort. Moreover, to adjust for baseline differences, propensity score matching was performed to examine the frequency of these outcomes in the total cohort (n = 132 pairs) and the early survivors (n = 110 pairs). Late survival was estimated by the Kaplan-Meier method, and risk of late mortality was assessed by Cox proportional hazards regression.
Results
Incidental splenectomy was performed in 135 patients (13%), 36% of whom underwent reoperation. Operative mortality rates of the incidental splenectomy and nonincidental splenectomy groups were 16% versus 8% in both the overall study (P = .005) and the propensity score-matched (P = .07) cohorts. In multivariable analysis, incidental splenectomy independently predicted operative mortality (odds ratio, 2.2; 95% confidence interval, 1.21-3.94; P = .008). For early survivors, incidental splenectomy did not increase the risk of late mortality. Survival estimates of matched early survivors did not differ between the incidental splenectomy and nonincidental splenectomy groups (P = .29).
Conclusions
Incidental splenectomy during thoracoabdominal aortic aneurysm repair was associated with increased operative mortality but not reduced late survival. Splenic preservation is encouraged when feasible.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Chatterjee S, LeMaire SA, Green SY, Price MD, ... Todd SR, Coselli JS
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31597614
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Abstract

Survival results in biphasic malignant pleural mesothelioma patients: A multicentric analysis.

Lococo F, Torricelli F, Lang-Lazdunski L, Veronesi G, ... Ciarrocchi A, Billè A
Objective
The best strategy of care for biphasic malignant pleural mesothelioma (Biph-MPM) is controversial. In this study, a large dataset of Biph-MPM cases was reviewed to identify prognostic factors and to evaluate the role of a multimodal approach, including cancer-directed surgery.
Methods
A total of 213 patients with Biph-MPM treated at 4 tertiary centers who experienced MPM from January 2009 to December 2016 were selected, and clinical, pathologic, and surgical information was retrieved. A Cox regression model was used to identify predictors of survival, and the Kaplan-Meier method was used to summarize overall survival.
Results
The mean age and the male/female ratio were 68.4 ± 9.5 years and 5:1, respectively. Tumors were assigned to stages I (127, 59.6%), II (3, 1.4%), III (76, 35.4%), and IV (7, 3.3%) according to the Eighth Tumor, Node, Metastasis (TNM) edition. A multimodal treatment including pleurectomy/decortication was performed in 58 patients (27.2%), chemotherapy alone in 99 patients (46.5%), and best supportive care in 56 (26.3%). The median overall survival was 11 months. A univariate analysis revealed that survival was significantly associated with the percentage forced expiratory volume in 1 second (P < .0001), performance status (P = .0002), multimodal treatment including surgery (P < .0001), and TNM stage (P = .011). A multivariable analysis confirmed performance status, percentage forced expiratory volume in 1 second, TNM, and a multimodal approach as independent variables affecting long-term survival.
Conclusions
Despite the overall poor prognosis of biphasic histology, a multimodal approach, including cancer-directed surgery, is associated with improved long-term results in very selected patients with Biph-MPM.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print
Lococo F, Torricelli F, Lang-Lazdunski L, Veronesi G, ... Ciarrocchi A, Billè A
J Thorac Cardiovasc Surg: 08 Sep 2019; epub ahead of print | PMID: 31590954
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Abstract

Flow disturbances and the development of endocardial fibroelastosis.

Weixler V, Marx GR, Hammer PE, Emani SM, Del Nido PJ, Friehs I
Objectives
Endothelial-to-mesenchymal transition (EndMT) has been identified as the underlying mechanism of endocardial fibroelastosis (EFE) formation. The purpose of this study was to determine whether hemodynamic alterations due to valvar defects promote EndMT and whether age-specific structural changes affect ventricular diastolic compliance despite extensive surgical resection of EFE tissue.
Material and methods
We analyzed EFE tissue from 24 patients with hypoplastic left heart syndrome (HLHS) who underwent left ventricular (LV) rehabilitation surgery at Boston Children\'s Hospital between December 2011 and March 2018. Six patients with flow disturbances across the aortic valve and/or mitral valve but no HLHS diagnosis and macroscopic appearance of \"EFE-like tissue\" in the LV were included for comparison. All samples were examined for amount of collagen/elastin production and degradation, and presence of active EndMT by histologic analysis.
Results
EFE tissue from patients with and without HLHS consisted predominantly of elastin and collagen fibers. There was no alteration in degradation activity for collagen or elastin as shown by in situ zymography. Active EndMT was found in all patients with and without HLHS with flow disturbances (\"EFE-like\"). In patients with HLHS, EFE infiltrated into the underlying myocardium with increasing age.
Conclusions
Patients with and without HLHS with flow disturbances due to stenotic or incompetent valves develop EndMT-derived fibrotic tissue covering the LV. When EFE recurs, it is directly associated with flow disturbances and switches to an infiltrative growth pattern with increasing age, leading to increased diastolic stiffness of the LV.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print
Weixler V, Marx GR, Hammer PE, Emani SM, Del Nido PJ, Friehs I
J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print | PMID: 31668539
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Abstract

Specialist training for cardiothoracic surgery in the Nordic countries.

Mennander A, Gudbjartsson T, Jeppsson A, Hjortdal V, Tønnessen T

Sweden, Denmark, Finland, Norway, and Iceland form the 5 culturally uniform Nordic countries. Each of the countries owns a high-standard tradition of individual steering in cardiothoracic education aiming at securing the needs and features of the local area. Indisputably, mastering a Nordic language and applying a high-standard individual steering in education ensure that a dedicated trainee is selected to the cardiothoracic program in accordance with the needs and features of the local area.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print
Mennander A, Gudbjartsson T, Jeppsson A, Hjortdal V, Tønnessen T
J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print | PMID: 31590947
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Abstract

Pulmonary artery banding in complete atrioventricular septal defect.

Devlin PJ, Jegatheeswaran A, McCrindle BW, Karamlou T, ... Meyer DB, Overman DM
Objectives
To analyze outcomes after pulmonary artery banding (PAB) in complete atrioventricular septal defect (AVSD), with a focus on surgical pathway outcome and timing, survival, and atrioventricular valve function.
Methods
PAB was performed in 50 of 474 infants (11%) from 28 institutions between 2012 and 2018 at a median age of 1.1 months. The median duration of follow-up was 2.1 years. Atrioventricular valve function was assessed by review of pre-PAB and predischarge echocardiograms (median, 9 days postoperatively). Competing-risks methodology was used to analyze the risks for biventricular repair, univentricular repair, and death.
Results
At 2 years, the proportions of patients who underwent biventricular repair, univentricular repair, and death were 68%, 13%, and 12%, respectively, with 8% awaiting definitive repair. After PAB, atrioventricular valve regurgitation decreased in 14 infants and increased in 10, but the distribution of regurgitation severity did not change significantly in the total cohort or subgroups. The intended management plan at PAB was deferred biventricular/univentricular decision (23 infants), 2-stage biventricular repair (24 infants), and univentricular repair (3 infants). Among the 24 infants intended for biventricular repair, 23 achieved biventricular repair and 1 died before repair. Survival at 4 years after biventricular repair among patients with previous PAB (93%) was similar to the 4-year survival of the patients who underwent primary biventricular repair (91%; n = 333).
Conclusions
PAB is a successful strategy in complete AVSD to bridge to biventricular repair and has similar post-biventricular repair survival to primary biventricular repair. Changes in atrioventricular valve regurgitation after PAB were variable.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 23 Sep 2019; epub ahead of print
Devlin PJ, Jegatheeswaran A, McCrindle BW, Karamlou T, ... Meyer DB, Overman DM
J Thorac Cardiovasc Surg: 23 Sep 2019; epub ahead of print | PMID: 31669019
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Abstract

Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST elevation.

Ram E, Sternik L, Klempfner R, Iakobishvili Z, ... Shlomo N, Raanani E
Objective
To compare short- and long-term outcomes of patients hospitalized with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA) who were referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-world national cohort.
Methods
This observational study included 5112 patients, who underwent either CABG or PCI, admitted for NSTEMI or UA and were enrolled in the Acute Coronary Syndrome Israeli Survey between 2000 and 2016. Propensity score-matching analysis compared early outcomes and all-cause mortality in patients who underwent revascularization by PCI with revascularization by CABG.
Results
Of the 5112 patients, 4327 (85%) underwent PCI and 785 (15%) CABG. Following propensity score analysis, 447 pairs were chosen (1:1). Independent predictors for CABG referral included 3-vessel CAD (odds ratio [OR], 5.5; 95% confidence interval [CI], 4.5-6.7, P < .001), absence of on-site cardiac surgery (OR, 1.3; 95% CI, 1.1-1.6, P = .004), no previous PCI (OR, 1.5; 95% CI, 1.2-1.9, P = .002) and no previous myocardial infarction (OR, 1.3; 95% CI, 1-1.7, P = .022). The 10-year mortality risk was significantly lower among those who underwent CABG compared with PCI (20.4% vs 28.4%, P = .006). Consistent with these findings, multivariable analysis showed that referral to CABG was independently associated with a significant 65% reduction in the risk of 10-year mortality (P < .001). This long-term advantage was seen among male patients (P < .001) and not female patients (P = .910).
Conclusions
In a real-life setting, revascularization by CABG provides excellent long-term outcomes in patients with NSTEMI or UA. The advantage of CABG over PCI was seen only in male patients.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print
Ram E, Sternik L, Klempfner R, Iakobishvili Z, ... Shlomo N, Raanani E
J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print | PMID: 31653430
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Abstract

Repair of double outlet right ventricle: Midterm outcomes.

Oladunjoye O, Piekarski B, Baird C, Banka P, ... Del Nido PJ, Emani SM
Objective
Double outlet right ventricle (DORV) is a complex cardiac malformation with many anatomic variations and various approaches for surgical repair. This study aimed to describe the clinical outcomes of biventricular (BiV) repair for DORV.
Methods
Patients with DORV, who underwent BiV repair between January 2000 and December 2017 were retrospectively reviewed. Group 1 underwent primary BiV repair, whereas group 2 underwent staged BiV repair over a series of operations. The decision to pursue staged approach included complexity of intracardiac anatomy, age of the patient, and the size and function of the ventricles and the atrioventricular valves. Time-dependent surgical reintervention for LVOTO and mortality were evaluated using Kaplan-Meier survival analysis.
Results
A total of 238 patients with DORV underwent BiV repair at a median age of 6.2 months (range, 1.1 month-27.5 years) (158 in group 1, 80 in group 2). Twenty-two patients (7.8%) required surgical reintervention within 30 days of BiV repair. Overall survival at 5 years was 89.0%. Freedom from LVOTO reoperation at 5 years was 84%. Primary outcomes were not significantly different between groups. CAVC repair and right ventricle to pulmonary artery conduit at BiV repair were associated with higher surgical reintervention (hazard ratio, 2.9 and 1.75, respectively).
Conclusions
Patients with DORV and complex anatomy may undergo staged BiV repair with acceptable outcomes. Although LVOTO is a potential complication in these patients, the rate of surgical reintervention for LVOTO does not differ significantly from patients undergoing primary BiV repair.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 29 Aug 2019; epub ahead of print
Oladunjoye O, Piekarski B, Baird C, Banka P, ... Del Nido PJ, Emani SM
J Thorac Cardiovasc Surg: 29 Aug 2019; epub ahead of print | PMID: 31597616
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Abstract

Endosonography with lymph node sampling for restaging the mediastinum in lung cancer: A systematic review and pooled data analysis.

Jiang L, Huang W, Liu J, Harris K, ... He J,
Background
Mediastinal restaging after induction treatment is still a difficult and controversial issue. We aimed to investigate the diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration for restaging the mediastinum after induction treatment in patients with lung cancer.
Methods
Embase and PubMed databases were searched from conception to March 2019. Data from relevant studies were analyzed to assess sensitivity and specificity of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration, and to fit the hierarchical summary receiver operating characteristic curves.
Results
A total of 10 studies consisting of 558 patients fulfilled the inclusion criteria. All patients were restaged by endobronchial ultrasound-guided transbronchial needle aspiration, endoscopic ultrasound-guided fine-needle aspiration, or both. Negative results were confirmed by subsequent surgical approaches. There were no complications reported during any endosonography approaches reviewed. The pooled sensitivities of endobronchial ultrasound-guided transbronchial needle aspiration and endoscopic ultrasound-guided fine-needle aspiration were 65% (95% confidence interval [CI], 52-76) and 73% (95% CI, 52-87), respectively, and specificities were 99% (95% CI, 78-100) and 99% (95% CI, 90-100), respectively. The area under the hierarchical summary receiver operating characteristic curves were 0.85 (95% CI, 0.81-0.88) for endobronchial ultrasound-guided transbronchial needle aspiration and 0.99 (95% CI, 0.98-1) for endoscopic ultrasound-guided fine-needle aspiration. Moreover, for patients who received chemotherapy alone, the pooled sensitivity of endosonography with lymph node sampling for restaging was 66% (95% CI, 56-75), and specificity was 100% (95% CI, 34-100); for patients who received chemoradiotherapy, the results seemed similar with a sensitivity of 77% (95% CI, 47-92) and specificity of 99% (95% CI, 48-100).
Conclusions
Endosonography with lymph node sampling is an accurate and safe technique for mediastinal restaging of lung cancer.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Jiang L, Huang W, Liu J, Harris K, ... He J,
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31590952
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Abstract

Intracavitary cisplatin-fibrin chemotherapy after surgery for malignant pleural mesothelioma: A phase I trial.

Opitz I, Lauk O, Meerang M, Jetter A, ... Stahel RA, Weder W
Objectives
Intracavitary chemotherapy is a promising concept to improve local tumor control for malignant pleural mesothelioma with reported high morbidity rates. We have demonstrated that administration of cisplatin loaded to fibrin increased local drug concentration and reduced systemic toxicity in preclinical models. We present a phase I trial of intracavitary cisplatin-fibrin after surgical tumor resection.
Methods
A total of 12 patients (75% International Mesothelioma Interest Group stage III-IV) were treated with 4 dose levels of intracavitary cisplatin-fibrin (11-44 mg/m body surface area) in a dose-escalating design. Cisplatin-fibrin was sprayed on the resected surfaces after pleurectomy/decortication. Blood and tissue samples were taken to assess toxicity and pharmacokinetics. Patients were regularly followed up.
Results
No dose-limiting toxicity was observed. Major morbidity occurred in 4 patients (33%). The 30-day and 90-day mortality were both 0%. Of 80 adverse events, 9 were classified serious, but none of these were related to study treatment. Local cisplatin concentration in the chest wall tissue was high at all dose levels (median, 46.3 μg/g [12-133 μg/g]). In serum, median cisplatin area under the concentration time curve values were always below renal toxicity levels. The median overall survival with 95% confidence interval was 21 months (10-31 months). In 1 patient with epithelioid malignant pleural mesothelioma (International Mesothelioma Interest Group stage I), there was no sign of relapse 48 months after treatment (44 mg/m body surface area).
Conclusions
The administration of intracavitary cisplatin-fibrin is safe with favorable pharmacokinetics. Although most patients had advanced disease, long-term outcomes are comparable to other multimodal concepts. A confirmation phase II trial is ongoing.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print
Opitz I, Lauk O, Meerang M, Jetter A, ... Stahel RA, Weder W
J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print | PMID: 31590949
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Abstract

Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair.

Norton EL, Wu X, Kim KM, Patel HJ, Deeb GM, Yang B
Objective
To compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair.
Methods
From 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.
Results
The demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46.
Conclusions
In ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print
Norton EL, Wu X, Kim KM, Patel HJ, Deeb GM, Yang B
J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print | PMID: 31587891
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Abstract

Maladaptive remodeling of pulmonary artery root autografts after Ross procedure: A proteomic study.

Chiarini A, Dal Prà I, Faggian G, Armato U, Luciani GB
Objective
Pulmonary autograft root dilatation is the major long-term complication after Ross procedure and the leading cause for reoperation. However, the mechanisms underlying dilatation remain to be elucidated. This study analyzed the proteomic changes seen in the dilated pulmonary autograft compared with normal pulmonary artery and aorta tissues.
Methods
Pulmonary autograft surgical samples were taken from 9 consecutive patients (mean age 37 ± 14; 15-51 years) with mean diameters of 5.2 ± 0.5 cm (4.6-5.8 cm) reoperated 8 to 16 years after Ross procedure. Control pulmonary artery and aorta samples were from 7 age- and sex-matched cardiac donors. Tunicae mediae from all samples were processed for proteomic analysis via 2-dimensional electrophoresis, matrix-assisted-laser-desorption-ionization-time of flight/mass spectrometry, and bioinformatics. The thus-identified putatively relevant proteins were validated via Western immunoblotting.
Results
Pulmonary autograft proteome features differed markedly from control pulmonary arteries, since proteins related to focal adhesions (eg, paxillin), cytoskeleton (eg, vimentin), and metalloprotease-regulating proteoglycans (eg, testican-2) were significantly up-regulated, whereas significant decreases occurred in microfibril-associated glycoprotein1, which controls elastic fiber buildup. Profound changes also occurred in cell-signaling proteins, ie, increases in soluble Jagged-1 fragment and ectodysplasin-2 receptor, and decreases in Notch-1 intracellular domain fragment. Moreover, pulmonary autograft expression levels of Paxillin, Vimentin, Jagged-1 fragment, and Notch1 intracellular domain fragment also differed from those of control aorta.
Conclusions
This study provides the first description of the specific proteomic features of dilated pulmonary autograft tunica media, which separate them sharply not only from those of control pulmonary artery and aorta but also of aortic aneurysms. These findings suggest that dilated pulmonary autografts undergo a unique maladaptive remodeling process deserving further investigation.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Chiarini A, Dal Prà I, Faggian G, Armato U, Luciani GB
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31585756
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Abstract

Clamping versus nonclamping thoracoscopic box ablation in long-standing persistent atrial fibrillation.

Harlaar N, Verberkmoes NJ, van der Voort PH, Trines SA, ... Braun J, van Brakel TJ
Objective
To compare clinical outcomes of clamping devices and linear nonclamping devices for isolation of the posterior left atrium (box) in thoracoscopic ablation of long-standing persistent atrial fibrillation.
Methods
Eighty patients who underwent thoracoscopic pulmonary vein and box isolation using a bipolar clamping device (42 patients) or bipolar nonclamping device (38 patients) to create the roof/inferior lesions for box isolation were included from 2 centers. Follow-up consisted of 24-hour Holter at regular intervals. Freedom from AF during 1-year follow-up and catheter repeat interventions were compared between groups.
Results
Acute intraoperative electrical isolation of the box compartment was significantly higher in the clamping group than in the nonclamping group (100% and 79%, respectively, P < .01). At 1-year follow-up, 91% of the clamping group and 79% of the nonclamping group were in sinus rhythm. During 1-year follow-up, recurrence rates did not significantly differ between the 2 groups (P = .08). Repeat catheter interventions were required in 10% of the clamping group and 21% of the nonclamping group (P = .15). Conduction gaps in the roof or inferior lesions were found in 1 patient (2%) in the clamping group versus 4 patients (11%) in the nonclamping group (P = .13).
Conclusions
Thoracoscopic pulmonary vein and box isolation are highly effective in restoring sinus rhythm in long-standing persistent atrial fibrillation on short-term follow-up. Comparison of clamping and nonclamping devices revealed lower rates of intraoperative exit block of the box in the nonclamping group. However, this did not translate into a significant difference in atrial fibrillation freedom at short-term (1-year) follow-up.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Harlaar N, Verberkmoes NJ, van der Voort PH, Trines SA, ... Braun J, van Brakel TJ
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31585753
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Abstract

Secondary repair of incompetent pulmonary valves after previous surgery or intervention: Patient selection and outcomes.

Adamson GT, McElhinney DB, Lui G, Meadows AK, ... Hanley FL, Maskatia SA
Objectives
Pulmonary valve (PV) regurgitation (PR) is common after intervention for a hypoplastic right ventricular outflow tract. Secondary PV repair is an alternative to replacement (PVR), but selection criteria are not established. We sought to elucidate preoperative variables associated with successful PV repair and to compare outcomes between repair and PVR.
Methods
Patients who underwent surgery for secondary PR from 2010 to 2017 by a single surgeon were studied. The PV annulus and leaflets were measured on the preoperative echocardiogram and magnetic resonance images, and the primary predictor variable was leaflet area indexed to ideal PV annulus area (iPLA) by magnetic resonance imaging. PV repair and PVR groups were compared using multivariable logistic regression, and with a conditional inference tree. Freedom from PV dysfunction and from reintervention were assessed with Kaplan-Meier survival analyses.
Results
Of 85 patients, 31 (36%) underwent PV repair. By multivariable analysis, longer PV total leaflet length (cm/m) (β = 3.00, standard error [SE] = 0.82, P < .001), larger PV z score (β = 1.34, SE = 0.39, P = .001), and larger iPLA (β = 8.13, SE = 2.62, P = .002) were associated with repair. iPLA of 0.90 or greater was 91% sensitive and 83% specific for achieving PV repair. At a median of 4.1 years follow-up, there was greater freedom from significant PR in the PV repair group (log rank P = .008).
Conclusions
Patients with an iPLA >0.9, and those with an iPLA between 0.7 and 0.9 with a PV annulus z score >0 should be considered for a native PV repair. At midterm follow-up, patients with a PV repair were not more likely to develop PR or to require reintervention when compared with patients undergoing PVR.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Adamson GT, McElhinney DB, Lui G, Meadows AK, ... Hanley FL, Maskatia SA
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31585750
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Abstract

Long-term outcomes of chordal replacement with expanded polytetrafluoroethylene sutures to repair mitral leaflet prolapse.

David TE, David CM, Lafreniere-Roula M, Manlhiot C
Objectives
This study examines the durability of mitral valve (MV) repair for mitral regurgitation using chordal replacement with expanded polytetrafluoroethylene sutures to correct leaflet prolapse.
Methods
Isolated chordal replacement was used to correct prolapse in 186 (24.9%) patients and combined with leaflet resection in 560 (75.1%). Patients were followed prospectively with periodical clinical and echocardiographic assessments for a median follow-up of 11 years (range, 7-16 years).
Results
Patients\' median age was 58 years (range, 48-67 years) and 516 (69.2%) were men. Bileaflet prolapse was present in 63% of patients and advanced myxomatous degeneration was present in 32%. The number of neochords per repaired valve increased over time and was not associated with MV reoperation or recurrent mitral regurgitation. The cumulative incidence of MV reoperation with death as a competing risk was 4.2% (95% confidence interval [CI], 2.4-6.0) at 20 years. Multivariable analysis revealed that previous cardiac operations (hazard ratio, 5.70; 95% CI, 1.96-16.53; P = .001), and isolated anterior leaflet prolapse (hazard ratio, 3.92; 95% CI, 1.106-13.91; P = .034) were associated with increased hazard of MV reoperation. The probability of recurrent moderate or severe mitral regurgitation using repeated measures regression models was 14.1% (95% CI, 10.3-19.0) at 20 years. Variables associated with recurrent MR in multivariable regression analysis were left ventricular ejection <40% (hazard ratio, 3.57; 95% CI, 1.37-9.32; P = .009) and preoperative complete heart block (hazard ratio, 5.90; 95% CI, 2.47-14.09; P < .001).
Conclusions
Chordal replacement with expanded polytetrafluoroethylene sutures provides stable MV function in most patients during the first 2 decades of follow-up.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Aug 2019; epub ahead of print
David TE, David CM, Lafreniere-Roula M, Manlhiot C
J Thorac Cardiovasc Surg: 29 Aug 2019; epub ahead of print | PMID: 31570218
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Abstract

Preischemic autologous mitochondrial transplantation by intracoronary injection for myocardial protection.

Guariento A, Blitzer D, Doulamis I, Shin B, ... Del Nido PJ, McCully JD
Objective
To investigate preischemic intracoronary autologous mitochondrial transplantation (MT) as a therapeutic strategy for prophylactic myocardial protection in a porcine model of regional ischemia-reperfusion injury (IRI).
Methods
The left coronary artery was cannulated in Yorkshire pigs (n = 26). Mitochondria (1 × 10) or buffer (vehicle [Veh]) were delivered as a single bolus (MT) or serially (10 injections over 60 minutes; MT). At 15 minutes after injection, the heart was subjected to temporary regional ischemia (RI) by snaring the left anterior descending artery. After 30 minutes of RI, the snare was released, and the heart was reperfused for 120 minutes.
Results
Coronary blood flow (CBF) and myocardial function were increased temporarily during the pre-RI period. Following 30 minutes of RI, MT and MT hearts had significantly increased CBF that persisted throughout reperfusion (Veh vs MT and MT; P = .04). MT and MT showed a significantly enhanced ejection fraction (Veh vs MT, P < .001; Veh vs MT, P = .04) and developed pressure (Veh vs MT, P < .001; Veh vs MT, P = .03). Regional function, assessed through segmental shortening (Veh vs MT, P = .03; Veh vs MT, P < .001), fractional shortening (Veh vs MT, P < .001; Veh vs MT, P = .04), and strain analysis (Veh vs MT, P = .002; Veh vs MT, P = .003), was also significantly improved. Although there was no difference in the area at risk between treatment groups, infarct size was significantly reduced in both MT groups (Veh vs MT and MT, P < .001).
Conclusions
Preischemic MT by single or serial intracoronary injections provides prophylactic myocardial protection from IRI, significantly decreasing infarct size and enhancing global and regional function.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Guariento A, Blitzer D, Doulamis I, Shin B, ... Del Nido PJ, McCully JD
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31564546
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Impact:
Abstract

Outcomes in patients with solid organ transplants undergoing cardiac surgery.

Bianco V, Kilic A, Gleason TG, Aranda-Michel E, ... Navid F, Sultan I
Objective
Long-term outcomes after cardiac surgery in solid organ transplant recipients are limited in the contemporary literature. The objective of this study is to evaluate postoperative outcomes in these patients, including variables associated with mortality and readmissions.
Methods
All adults undergoing isolated coronary artery bypass grafting, isolated valve, or coronary artery bypass grafting + valve cardiac surgical procedures from 2011 to 2018 were included in this study. Patients with solid organ transplants undergoing cardiac surgery were studied. Primary outcomes included operative (30-day) and 5-year mortality.
Results
A total of 11,190 patients underwent isolated coronary artery bypass grafting, isolated valve, or coronary artery bypass grafting + valve operations at our institution from 2011 to 2018. Of these, 129 patients (1%) had solid organ transplants and underwent isolated coronary artery bypass grafting (n = 84), isolated valve (n = 30), or coronary artery bypass grafting + valve (n = 15). Type of organ transplant included 84 patients (65%) with kidney, 27 patients (21%) with liver, 9 patients (7%) with heart, and 9 patients (7%) with lung transplants. The median Society of Thoracic Surgeons Predicted Risk Of Mortality for the cohort was 2.73 (Q1-Q3: 1.67-6.33). Three patients (2%) had an operative (30-day) mortality. Significant variables associated with 5-year mortality on multivariable Cox regression analysis included chronic obstructive pulmonary disease (hazard ratio, 2.44; 1.01-5.90; P = .048) and congestive heart failure (hazard ratio, 4.45; 1.81-10.9; P = .001). Significant variables associated with 5-year readmissions included chronic obstructive pulmonary disease, dialysis dependence, and concomittant valve surgery with coronary artery bypass grafting. Five-year readmission rate was 88%, and patients with valve operations (± coronary artery bypass grafting) had significantly lower (P = .009) freedom from readmission (6%).
Conclusions
Cardiac surgery can be performed with low operative mortality and good long-term survival in patients with solid organ transplants. Five-year hospital readmissions are common, with significantly more readmissions in patients who had valve procedures.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Bianco V, Kilic A, Gleason TG, Aranda-Michel E, ... Navid F, Sultan I
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31564544
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Impact:
Abstract

A novel target to reduce microglial inflammation and neuronal damage after deep hypothermic circulatory arrest.

Liu M, Li Y, Gao S, Yan S, ... Liu G, Ji B
Background
Neuroinflammation acts as a contributor to neurologic deficits after deep hypothermic circulatory arrest. However, the molecular mechanism remains unclear. This study postulates that cold-inducible RNA-binding protein can promote deep hypothermic circulatory arrest-induced neuroinflammation.
Methods
Rats were randomly assigned into 3 groups (n = 5, each group): sham group, deep hypothermic circulatory arrest group, and deep hypothermic circulatory arrest + Cirp group (Cirp group). Murine microglial BV2 cells were administered by adeno-associated viral vectors containing cold-inducible RNA-binding protein small interference RNA or negative control small interference RNA at 2 days before 4-hour oxygen-glucose deprivation at 18°C. Microglial activation, cell death, neuroinflammation, and related protein expression were assessed in tissue samples and cell cultures.
Results
Cold-inducible RNA-binding protein was elevated along with evident neuroinflammation and neuronal damage in rats exposed to deep hypothermic circulatory arrest. In Cirp rats, histologic injury (3.00 [interquartile range, 2.00-3.00] vs 1.00 [interquartile range, 1.00-1.50] neuropathological score, P < .001) and microglial activation (40 ± 4 vs 13 ± 7 CA1 area, P < .001) were alleviated after deep hypothermic circulatory arrest. With RNA-sequencing analysis, this associated with reduction of key proinflammatory cytokines induced by inhibiting Brd2-NF-κB signals. In BV2 cells treated with small interference RNA-cold-inducible RNA-binding protein, similar protective effects were observed, including decreased proinflammatory cytokines and cytotoxicity. Brd2-NF-κB signals were confirmed by the addition of Brd2 inhibitor JQ1. Notably, the conditioned medium from BV2 cells transfected with small interference RNA cold-inducible RNA-binding protein significantly reduced apoptosis in neural SH-SY5Y cells after oxygen-glucose deprivation, which was similar to that after JQ1 administration.
Conclusions
Enhanced cold-inducible RNA-binding protein in microglia aggravates neuronal injury by promoting the release of proinflammatory cytokines, which might be mediated through Brd2-NF-κB signals during deep hypothermic circulatory arrest.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Aug 2019; epub ahead of print
Liu M, Li Y, Gao S, Yan S, ... Liu G, Ji B
J Thorac Cardiovasc Surg: 28 Aug 2019; epub ahead of print | PMID: 31564537
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Impact:
Abstract

Distressed communities are associated with worse outcomes after coronary artery bypass surgery.

Mehaffey JH, Hawkins RB, Charles EJ, Thibault D, ... Badhwar V, Ailawadi G
Objectives
Although low socioeconomic status has been associated with increased risk of complications after cardiac surgery, analyses have typically focused on insurance status, race, or median income. We sought to determine if the Distressed Communities Index, a composite socioeconomic metric, could predict operative mortality after coronary artery bypass grafting.
Methods
All patients who underwent isolated coronary artery bypass grafting (2011-2018) in the National Society of Thoracic Surgeons adult cardiac surgery database were analyzed. Clinical data were paired with the Distressed Communities Index, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies by ZIP code. Developed by the Economic Innovation Group, Distressed Communities Index scores range from 0 (no distress) to 100 (severe distress). A distressed community was defined as one having a Distressed Communities Index of 75 or greater for univariate analyses.
Results
Of the 575,900 patients undergoing coronary artery bypass grafting with a Distressed Communities Index score, the median age was 65 years. The operative mortality rate was 2.0%, and the composite morbidity or mortality rate was 11.5%. Distressed communities were associated with increased Society of Thoracic Surgeons predicted risk of mortality (1.97% vs 1.85%, P < .0001) and risk of composite morbidity or mortality (12.8% vs 11.7%, P < .0001). After adjusting for Society of Thoracic Surgeons risk model, the Distressed Communities Index remained significantly associated with mortality (odds ratio, 1.12; P < .0001) and composite morbidity and mortality (odds ratio, 1.03; P = .002).
Conclusions
Patients from distressed communities are at increased risk for adverse events and death after coronary artery bypass grafting. The Distressed Communities Index is a useful, holistic measure of socioeconomic status that may help identify high-risk patients for quality improvement and should be considered when building risk models or comparing hospitals.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print
Mehaffey JH, Hawkins RB, Charles EJ, Thibault D, ... Badhwar V, Ailawadi G
J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print | PMID: 31543309
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Impact:
Abstract

Preemptive pain-management program is associated with reduction of opioid prescriptions after benign minimally invasive foregut surgery.

Kim MP, Godoy C, Nguyen DT, Meisenbach LM, ... Chan EY, Graviss EA
Objective
The opioid crisis is partly due to opioids prescribed after elective surgery. We sought to determine if a preemptive pain-management program would be associated with opioid-free discharge after benign foregut surgery.
Methods
A retrospective case-control study of prospectively collected data was conducted at a single institution of patients who underwent elective minimally invasive benign foregut surgery. We compared the outcomes among patients who were managed with standard care (control), enhanced recovery after surgery alone, or a preemptive pain-management program with enhanced recovery after surgery.
Results
Among 414 patients, there were significantly fewer opioid medication prescriptions at discharge (9.6% vs 85.2% vs 87%, P < .001) and fewer postoperative complications (3.2% vs 14.8% vs 15.1%, P = .004) in the preemptive pain-management group (n = 94), enhanced recovery after surgery alone (n = 81), and the control group (n = 239), respectively. Multivariable logistic regression analysis showed that the preemptive pain-management program was a factor associated with a decrease in opioid medication prescriptions at discharge (odds ratio, 0.01; 95% confidence interval, 0.01-0.03; P < .001), as well as a decrease in complications after surgery (odds ratio, 0.22; 95% confidence interval, 0.06-0.79; P = .02). Moreover, in the preemptive pain-management group, average self-reported pain level in a subset of patients at 30 days after surgery was 0.9 ± 1.4 on a 0- to 10-point pain scale.
Conclusions
The preemptive pain-management program was associated with opioid-free discharge after minimally invasive foregut surgery. This study provides a strategy to reduce opioid prescriptions after foregut surgery and, if implemented nationally, could decrease the amount of opioids used in the community.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print
Kim MP, Godoy C, Nguyen DT, Meisenbach LM, ... Chan EY, Graviss EA
J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print | PMID: 31582204
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Impact:
Abstract

Effects of genetic transfection on calcium cycling pathways mediated by double-stranded adeno-associated virus in postinfarction remodeling.

Katz MG, Gubara SM, Hadas Y, Weber T, ... Bridges CR, Fargnoli AS
Objective
Restoring calcium sensor protein (S100A1) activity in failing hearts poses a promising therapeutic strategy. We hypothesize that cardiac overexpression of the S100A1 gene mediated by a double-stranded adeno-associated virus (scAAV) results in better functional and molecular improvements compared with the single-stranded virus (ssAAV).
Methods
Heart failure was induced by coronary artery ligation. Then, intramyocardial injections of saline, AAV9 empty capsid, scAAV9.S100A1, and ssAAV9.S100A1 were performed. Ten weeks postinfarction, all rats received cardiac evaluation; serum and tissue were collected for genetic analysis, cytokine profiling, and assessments of mitochondrial function and structure.
Results
Overexpression of AAV9.S100A1 improved systolic and diastolic function. Compared with control, ejection fraction was greater in treated groups (54.8% vs 32.3%, P < .05). Similarly, end-diastolic volume index was significantly less in the treated group than in control (1.14 vs 1.59 mL/cm), whereas fractional shortening was greater in treated groups than control (26% vs 38%, P < .05). Interestingly, cardiac mechanics were significantly better when treated with double-stranded virus compared with single-stranded. Quantitative polymerase chain reaction demonstrated robust transfection of myocardium with the S100A1 gene, with more infection in the self-complimentary group compared with the single-stranded group (5.68 ± 0.44 vs 4.09 ± 0.25 log genome copies per 100 ng of DNA; P < .0001). Concentrations of the inflammatory cytokines were elevated in the ssAAV9/S100A1 group compared with the scAAV9/S100A1. Assessment of mitochondrial respiration and morphology demonstrated that injection of self-complementary vector saved both mitochondrial structure and function.
Conclusions
Gene therapy of S100A1 can prevent pathologic postmyocardial infarction remodeling and decrease inflammatory response in ischemic heart failure.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print
Katz MG, Gubara SM, Hadas Y, Weber T, ... Bridges CR, Fargnoli AS
J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print | PMID: 31679707
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Impact:
Abstract

Prospective, multicenter, international phase 2 trial evaluating ultrasonic energy for pulmonary artery branch sealing in video-assisted thoracoscopic surgery lobectomy.

Liberman M, Goudie E, Morse C, Hanna W, ... Sampalis J,
Objectives
The study objectives were to evaluate the immediate, short-, and medium-term efficacy and safety of pulmonary artery branch sealing using an ultrasonic vessel-sealing device in minimally invasive anatomic lung resection.
Methods
This study consists of a prospective, phase 2, multicenter, international clinical trial (clinicaltrials.gov: NCT02719717) that enrolled patients planned for video-assisted thoracoscopic surgery/robotic anatomic lung resection in 7 centers (United States, Canada, United Kingdom). Pulmonary artery branches of 7 mm or less were sealed and divided with an ultrasonic energy vessel-sealing device. The remainder of the lobectomy was performed according to surgeon preference. Intraoperative, in-hospital, and 30-day postoperative bleeding and complications were prospectively recorded.
Results
A total of 150 patients with a minimum of 1 pulmonary artery branch sealed with an ultrasonic vessel-sealing device were prospectively enrolled in the trial. Resections included 139 lobectomies and 11 segmentectomies. A total of 424 pulmonary artery branches were divided: 239 with the ultrasonic vessel-sealing device, 181 with endostaplers, and 4 with endoscopic clips. The mean and median pulmonary artery diameters were 4.7 mm/5.0 mm, 10.3 mm/10.0 mm, and 6.5 mm/6.5 mm for each method, respectively. Three of the pulmonary artery branches divided with the ultrasonic vessel-sealing device (1.3%) and 4 pulmonary artery branches divided with endostaplers (2.2%) bled intraoperatively. Among the patients with seal failures, 1 patient required conversion to thoracotomy. There was no postoperative bleeding from divided pulmonary artery branches with either sealing method. There was no mortality at 30 days.
Conclusions
Pulmonary artery branch sealing with ultrasonic energy during video-assisted thoracoscopic surgery lobectomy is safe for vessels 7 mm or less. The use of an ultrasonic device is a reasonable sealing method for pulmonary artery branches 7 mm or less.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print
Liberman M, Goudie E, Morse C, Hanna W, ... Sampalis J,
J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print | PMID: 31679701
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Impact:
Abstract

Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.

Norton EL, Williams DM, Kim KM, Khaja MS, ... Deeb GM, Yang B
Objective
The study objective was to evaluate the management of malperfusion in acute type B aortic dissection with endovascular fenestration/stenting.
Methods
From 1996 to 2018, 182 patients with an acute type B aortic dissection underwent fenestration/stenting for suspected malperfusion based on imaging, clinical manifestations, and laboratory findings. Data were obtained from medical record review and the National Death Index database.
Results
The median age of patients was 55 years. Signs of malperfusion included abdominal pain (61%), lower-extremity weakness (27%), nonpalpable lower-extremity pulses (24%), and abnormal lactate, creatinine, liver enzymes, and creatine kinase levels. Confirmed hemodynamically significant malperfusion affected the spinal cord (2.7%), celiac (24%), superior mesenteric (40%), renal (51%), and iliofemoral (43%) arterial distributions. Of the 182 patients, 99 (54%) underwent aortic fenestration/stenting, 108 (59%) had 1 or multi-branch vessel fenestration/stenting, 5 (2.7%) had concomitant thoracic endovascular aortic repair, 17 (9.3%) had additional thrombolysis or thromboembolectomy, and 48 (26%) received no intervention. After fenestration/stenting, 24 patients (13%) required additional procedures for necrotic bowel or limb and 9 patients (4.9%) had subsequent aortic repair (thoracic endovascular aortic repair, open repair) before discharge. The new-onset paraplegia was 0%. The in-hospital mortality was 7.7% over 20+ years and 0% in the last 8 years. The 5- and 10-year survivals were 72% and 49%, respectively. The significant risk factors for late mortality were age and acute paralysis (hazard ratio, 3.5; both P < .0001). Given death as a competing factor, the 5- and 10-year cumulative incidence of reintervention was 21% and 31% for distal aortic pathology, respectively.
Conclusions
Patients with acute type B aortic dissection with malperfusion can be managed with endovascular fenestration/stenting with excellent short- and long-term outcomes. This approach is particularly helpful to patients with static malperfusion of aortic branch vessels.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print
Norton EL, Williams DM, Kim KM, Khaja MS, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print | PMID: 31669033
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Impact:
Abstract

Evolving understanding of total artificial heart support of young infants and children.

Woods RK, Kindel S, Mitchell ME, Hraska V, Niebler RA
Background
We have developed a new method of total artificial heart (TAH) support for young patients, and here share our preliminary results and evolving understanding.
Methods
This report is a retrospective chart review of all patients <10 kg who received a TAH at our institution from May 2017 to the time of this report.
Results
Our cohort includes 5 patients. Two had single-ventricle circulation, 1 of whom had undergone a Glenn procedure and was revised back to a Sano shunt. Four were on extracorporeal life support for longer than 10 days, 3 with an open chest. In these 3 patients, the TAH was a salvage operation. Centrifugal pumps were used for 2 patients and pulsatile pumps for 3 patients. Three patients survived to transplantation and discharge, with support times of 79, 44, and 96 days; in these patients, the duration of follow-up from discharge to the time of this report was 687, 19, and 8 days, respectively, and all patients were well. For the pulsatile pumps, in the first patient we placed valved conduits for inflow connections. For the second patient, we omitted the valved conduits and oversized the pumps to avoid full fill; yet, despite our best efforts, full fill occurred frequently, and thus we converted to a systemic centrifugal pump.
Conclusions
Our method of TAH support can be tailored to provide effective support of carefully selected young children with single or biventricular physiology. In our opinion, for pulsatile pumps, oversizing the pump and using valved inflow conduits may be important adjuncts to achieve effective support.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Sep 2019; epub ahead of print
Woods RK, Kindel S, Mitchell ME, Hraska V, Niebler RA
J Thorac Cardiovasc Surg: 27 Sep 2019; epub ahead of print | PMID: 31669029
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Impact:
Abstract

Multidisciplinary selection of pulmonary nodules for surgical resection: Diagnostic results and long-term outcomes.

Madariaga ML, Lennes IT, Best T, Shepard JO, ... Gaissert HA,
Objective
Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile, and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported.
Methods
All patients evaluated at a PNLCSC from 2012 to 2018 following referral by primary care physicians, specialist physicians, or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival, and recurrence were compared.
Results
Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)-representing 3.3% (21/632) of all incidental nodules evaluated-than in the screening group (4%, 1/25) (P = .038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathologic stage Ia. Complete follow-up was available in 725 of 747 (97%), and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (P = .48).
Conclusions
A unique multidisciplinary PNLCSC for incidental and lung cancer screening-detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure, and cost control need further study.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 23 Sep 2019; epub ahead of print
Madariaga ML, Lennes IT, Best T, Shepard JO, ... Gaissert HA,
J Thorac Cardiovasc Surg: 23 Sep 2019; epub ahead of print | PMID: 31669016
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Impact:
Abstract

Organ-level vascularization: The Mars mission of bioengineering.

Zhang B, Radisic M

Organ-level vascularization has been a long-standing challenge in the field of tissue engineering. Recent advances, particularly in the use of projection stereolithography and food colors as photoabsorbers are highlighted, as are several recent studies on the clinical translation of engineered vasculature.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 22 Sep 2019; epub ahead of print
Zhang B, Radisic M
J Thorac Cardiovasc Surg: 22 Sep 2019; epub ahead of print | PMID: 31668537
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Impact:
Abstract

Thrombocytopenia after implantation of the Perceval S aortic bioprosthesis.

Stegmeier P, Schlömicher M, Stiegler H, Strauch JT, Bechtel JFM
Objective
The Perceval S bioprosthesis (LivaNova PLC, London, United Kingdom) is based on the Freedom Solo aortic bioprosthesis (LivaNova PLC), which has been reported to be associated with perioperative thrombocytopenia. We compared platelet counts after aortic valve replacement with the Perceval S with those with other aortic valve bioprostheses.
Methods
A total of 87 patients receiving aortic valve replacement were included in this retrospective study; 25 patients received the Perceval S, 23 patients received the Labcor TLPB-A (Labcor, Belo Horizonte, Brazil), and 39 patients received the Hancock II bioprosthesis (Medtronic, Minneapolis, Minn). Thrombocyte count was corrected for hematocrit. Multivariable analyses were performed to assess the potential effect of other variables.
Results
Preoperatively, there were no differences in platelet counts comparing the Perceval S group (median 200/nl, interquartile range, 157-252) and the control group (Labcor: median 213/nl, interquartile range, 160-246, Hancock: median 227/nl, interquartile range, 183-280, P = .23). Postoperatively, there was significant evidence that the minimum platelet count (median, Perceval: 47, interquartile range, 38-66; Labcor: 76, interquartile range, 61-110; Hancock: 78, interquartile range, 61-111/nl; P = .001), both absolute and corrected, was lower for the Perceval S, even after allowing for other variables. The significant difference in absolute platelet counts persisted until discharge or death. However, there were no significant differences regarding blood loss, transfusion requirements, or rates of reoperation for bleeding.
Conclusions
After aortic valve replacement, platelet counts in patients with the Perceval S decrease more severely compared with other bioprostheses, but in our small study we found no evidence of a detrimental clinical effect of this phenomenon. Future studies have to confirm our findings and investigate a cause for this phenomenon.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print
Stegmeier P, Schlömicher M, Stiegler H, Strauch JT, Bechtel JFM
J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print | PMID: 31668534
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Impact:
Abstract

Association between preoperative aspirin and acute kidney injury following coronary artery bypass grafting.

Aboul-Hassan SS, Marczak J, Stankowski T, Peksa M, ... Stanislawski R, Cichon R
Objective
To test the hypothesis that preoperative aspirin administered within 24 hours before coronary artery bypass grafting (CABG) could reduce the incidence of postoperative acute kidney injury (AKI) following CABG.
Methods
In this retrospective study, 696 patients were assigned to groups according to the time interval between their last aspirin dose administration and the time of surgery. A total of 322 patients received aspirin ≤24 hours before CABG, and 374 patients received aspirin between 24 and 48 hours before CABG. The primary outcome was postoperative AKI of any stage as defined by the Kidney Disease Improving Global Outcomes criteria. Propensity score matching selected 274 pairs for the final comparison.
Results
Multivariable analysis showed that administration of aspirin within 24 hours of CABG was independently associated with reduction of AKI incidence by 36% (odds ratio, 0.64; 95% confidence interval, 0.45-0.91; P = .014). It was also noted that patients receiving their last aspirin dose ≤24 hours before CABG had a significantly higher glomerular filtration rate at discharge compared with patients who received aspirin between 24 and 48 hours before CABG. Propensity score matching analysis showed that patients receiving aspirin within 24 hours before CABG had a lower incidence of AKI compared with patients who discontinued aspirin between 24 and 48 hours before CABG (25.1% vs 36.8%; P = .004).
Conclusions
Continuation of aspirin until the day of surgery, with the last aspirin dose administered ≤24 hours before CABG, is associated with a significant reduction of postoperative AKI.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print
Aboul-Hassan SS, Marczak J, Stankowski T, Peksa M, ... Stanislawski R, Cichon R
J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print | PMID: 31653428
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Impact:
Abstract

Effect of bilateral sympathectomy in a rat model of dilated cardiomyopathy induced by doxorubicin.

Coutinho E Silva RDS, Zanoni FL, Simas R, Martins da Silva MHF, ... Breithaupt Faloppa AC, Moreira LFP
Objective
The study objective was to evaluate the effect of bilateral sympathectomy on ventricular remodeling and function in a rat model of dilated cardiomyopathy induced by doxorubicin.
Methods
Dilated cardiomyopathy was induced in male Wistar rats by weekly intraperitoneal injection of doxorubicin (2 mg/kg) for 9 weeks. Animals were divided into 4 groups: dilated cardiomyopathy; bilateral sympathectomy, submitted on day 15 of the protocol to bilateral sympathectomy; angiotensin-converting enzyme inhibitor, treated with enalapril through day 15 until the end of the experimental protocol; and sham, nonsubmitted through doxorubicin protocol, with weekly intraperitoneal injections of saline solution (0.9%). The left ventricular function was assessed, and the heart was collected for posterior analyses.
Results
The dilated cardiomyopathy group presented a significant decrease in the myocardial efficiency when compared with the sham group (33.4% vs 71.2%). Only the bilateral sympathectomy group was able to preserve it (57.5%; P = .0001). A significant dilatation in the left ventricular chamber was observed in the dilated cardiomyopathy group (15.9 μm) compared with the sham group (10.2 μm; P = .0053). Sympathectomy and enalapril prevented ventricular remodeling (9.5 and 9.6 μm, respectively; P = .0034). There was a significant increase in interstitial myocardial fibrosis in the dilated cardiomyopathy group (14.8%) when compared with the sham group (2.4%; P = .0001). This process was significantly reduced with sympathectomy and enalapril (8.7 and 3.9%, respectively; P = .0001).
Conclusions
Bilateral sympathectomy was effective in preventing remodeling and left ventricular dysfunction in a rat model of dilated cardiomyopathy induced by doxorubicin.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print
Coutinho E Silva RDS, Zanoni FL, Simas R, Martins da Silva MHF, ... Breithaupt Faloppa AC, Moreira LFP
J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print | PMID: 31653422
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Impact:
Abstract

Management outcomes of primary pulmonary vein stenosis.

Rosenblum JM, Altin HF, Gillespie SE, Bauser-Heaton H, ... Cory M, Alsoufi B
Objectives
Primary pulmonary vein stenosis (PPVS) is increasingly diagnosed in children with no prior pulmonary vein intervention history, and management is challenging. We describe characteristics of patients who underwent surgical repair of PPVS at our center, and examine factors associated with treatment failures.
Methods
A retrospective review of all patients who underwent surgical intervention for PPVS (2002-2016) was completed. Patients who had undergone prior cardiac surgery involving the pulmonary veins or atrial switch were excluded. Regression analyses were performed to examine characteristics, PPVS features, including severity score, and surgical details associated with treatment failures.
Results
Thirty-four children underwent initial surgical intervention for PPVS. Median age was 8.9 months (interquartile range, 5.9-18.4 months). Most patients (n = 31; 91%) had unilateral pulmonary vein involvement and the median PPVS severity score was 3.5 (interquartile range, 3-5). On competing risk analysis, 1 year following surgical repair, 9% of patients had died, 14% had undergone reintervention, and 77% were alive without reintervention; at 5 years the numbers were 9%, 30%, and 61%, respectively. Factors associated with mortality included bilateral disease and PPVS severity score >6. Bilateral disease and PPVS severity score >5 were associated with reintervention risk.
Conclusions
Multidisciplinary management strategy is required for PPVS. Despite satisfactory early repair, patients continue to be at risk for recurrence and subsequent mortality, especially those with extensive primary involvement. The disappointing results underscore the need for multi-institutional collaborations to better understand this complex disease, establish management and follow-up protocols, and explore investigational treatment modalities that could modify the unfavorable outcome of this uncommon and challenging disease.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print
Rosenblum JM, Altin HF, Gillespie SE, Bauser-Heaton H, ... Cory M, Alsoufi B
J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print | PMID: 31648829
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Impact:
Abstract

Preoperative left atrial volume index is associated with postoperative outcomes in mitral valve repair for chronic mitral regurgitation.

Balachandran P, Schaff HV, Lahr BD, Nguyen A, ... Pislaru SV, Dearani JA
Objective
To assess determinants of left atrial reverse remodeling after mitral valve repair and to evaluate the impact of preoperative left atrial volume on postoperative outcomes.
Methods
We reviewed the records of 720 patients who underwent mitral valve repair from September 2008 to July 2015 and had preoperative measurement of left atrial volume index. We analyzed the association of preoperative left atrial volume index on early and late outcomes, and determined which baseline characteristics are associated with left atrial reverse remodeling, as measured by changes in left atrial volume index in 512 patients who had at least 1 postoperative measurement.
Results
The median (interquartile range) preoperative left atrial volume index was 54.0 (44.0-66.0) mL/m. Preoperative left atrial volume index, age, body mass index, and atrial fibrillation were independently associated with the degree of left atrial reverse remodeling over the follow-up period. Reverse remodeling was greatest in patients with higher baseline left atrial volume index (P < .001), but less reverse remodeling was observed in patients with advanced age (P < .001), preoperative atrial fibrillation (P < .001), and extreme values of body mass index (P = .004), although these effects were moderately attenuated when limiting the analysis to 6-month follow-up. Secondary analysis demonstrated marginally significant effects of preoperative left atrial volume index on risks of early postoperative atrial fibrillation (P = .030) and late mortality (P = .077) after adjusting for age and sex.
Conclusions
In patients with degenerative mitral valve regurgitation who had mitral valve repair, preoperative left atrial volume index was associated with extent of left atrial reverse remodeling, risk of early postoperative atrial fibrillation, and late mortality. The majority of reverse remodeling occurs within the first month after operation and is greatest in younger patients.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 16 Sep 2019; epub ahead of print
Balachandran P, Schaff HV, Lahr BD, Nguyen A, ... Pislaru SV, Dearani JA
J Thorac Cardiovasc Surg: 16 Sep 2019; epub ahead of print | PMID: 31627945
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Impact:
Abstract

Does the prognostic nutritional index have a predictive role in the outcomes of adult cardiac surgery?

Lee SI, Ko KP, Choi CH, Park CH, Park KY, Son KH
Objective
Malnutrition is known to affect postoperative outcomes, but only a limited number of assessment methods are available for evaluating nutritional status before cardiac surgery. The purpose of this study was to investigate the clinical significance of the prognostic nutritional index for adult patients undergoing cardiac surgery.
Methods
We retrospectively reviewed the medical records of 374 patients aged more than 18 years who underwent cardiac surgery with cardiopulmonary bypass. Patients were divided into 2 groups based on the cutoff prognostic nutritional index, and these groups were compared with respect to early morbidity and mortality rates, intensive care unit stays, and long-term outcomes. Logistic regression analyses were performed to identify the risk factors of early outcomes.
Results
The calculated cutoff value of the prognostic nutritional index was 46.13. Early mortality and morbidity were significantly more common in the high-risk group (9.0% vs 2.9%: P = .02, 58.0% vs 42.0%: P = .01). The median duration of mechanical ventilation support (18.0 vs 16.0 hours: P < .01) and intensive care unit stays (3.0 vs 2.0 days: P < .01) were also longer in the high-risk group. However, no significant intergroup difference was observed for the long-term clinical outcomes. Multivariate analysis showed that the prognostic nutritional index, age, cardiopulmonary bypass time, and aortic crossclamp time independently predicted early outcomes. Of these, only the prognostic nutritional index and age were significant preoperative variables (P = .01 and P < .01).
Conclusions
The prognostic nutritional index may be a useful preoperative nutrition screening tool for predicting the early clinical outcomes of adult patients after cardiac surgery using cardiopulmonary bypass.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 18 Sep 2019; epub ahead of print
Lee SI, Ko KP, Choi CH, Park CH, Park KY, Son KH
J Thorac Cardiovasc Surg: 18 Sep 2019; epub ahead of print | PMID: 31627943
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Impact:
Abstract

Factors associated with nodal metastasis in 2-centimeter or less non-small cell lung cancer.

Pani E, Kennedy G, Zheng X, Ukert B, ... Kucharczuk J, Singhal S
Objective
Lymph node involvement is an important determinant of treatment and prognosis in non-small cell lung cancer (NSCLC) and must be determined via surgical lymph node (LN) evaluation. However, lymphadenectomy is associated with multiple significant morbidities. Recent studies have suggested LN evaluation can be foregone in some or all patients with NSCLC ≤2.0 cm. Our objective was to identify whether these patients may be safely spared the morbidity of lymphadenectomy.
Methods
We undertook a retrospective study of patients treated for NSCLC ≤2.0 cm at a single institution from 2005 to 2017. We examined patient, demographic, and tumor variables for associations with LN metastases via univariable and multivariable analyses.
Results
In total, 555 patients met our inclusion criteria. Our primary independent variables included tumor size, histology, and histologic subtype. Although tumors ≤1 cm were less likely to have LN metastases than 1.1- to 2-cm tumors (6.8% vs 13.3%), there was no statistically significant difference. Histologic type was not associated with LN status. In an adenocarcinoma subgroup analysis, micropapillary predominant tumors were more likely to have LN metastases. All invasive mucinous adenocarcinomas and minimally invasive adenocarcinomas were N0.
Conclusions
LN evaluation may be unnecessary in patients with minimally invasive adenocarcinoma or invasive mucinous adenocarcinomas ≤2.0 cm. However, this information is rarely available pre- or intraoperatively. Thus, we recommend LN evaluation always be performed when possible, even for subcentimeter NSCLC, unless the histology is absolutely certain. To our knowledge, this is the largest dataset published to study patients with NSCLC ≤2.0 cm.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Pani E, Kennedy G, Zheng X, Ukert B, ... Kucharczuk J, Singhal S
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31610968
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Impact:
Abstract

Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol.

Krebs ED, Mehaffey JH, Sarosiek BM, Blank RS, Lau CL, Martin LW
Objectives
Video-assisted thoracoscopic surgery lobectomy has been associated with improved pain, length of stay, and outcomes compared with open lobectomy. However, enhanced recovery protocols improve outcomes after both procedures. We aimed to compare video-assisted thoracoscopic surgery and open lobectomy in the setting of a comprehensive enhanced recovery protocol.
Methods
All patients undergoing lobectomy for lung cancer at a single institution since the adoption of an enhanced recovery protocol (May 2016 to December 2018) were stratified by video-assisted thoracoscopic surgery versus open status and compared. Demographics and outcomes, including length of stay, daily pain scores, and short-term operative complications, were compared using standard univariate statistics and multivariable models.
Results
A total of 130 patients underwent lobectomy, including 71 (54.6%) undergoing video-assisted thoracoscopic surgery and 59 (45.4%) undergoing open surgery. Video-assisted thoracoscopic surgery versus open cases exhibited similar length of stay (median 4 days for both, P = .07), opioid requirement (33.2 vs 30.8 mg morphine equivalents, P = .86), and pain scores at 0, 1, 2, and 3 days after surgery (4.3 vs 2.8, P = .12; 4.4 vs 3.7, P = .27; 3.9 vs 3.5, P = .83; and 3.4 vs 3.5, P = .98, respectively). Patients undergoing video-assisted thoracoscopic surgery lobectomy exhibited lower rates of readmission (1.4% vs 17.0%, P < .01), postoperative transfusion requirement (0% vs 10.2%, P < .01), and pneumonia (1.4% vs 10.2%, P = .05). After risk adjustment, an open procedure (vs video-assisted thoracoscopic surgery status) did not significantly affect the length of stay (effect 0.18; P = .10) or overall complication rate (odds ratio, 1.9; P = .12).
Conclusions
In the setting of a comprehensive enhanced recovery protocol, patients undergoing video-assisted thoracoscopic surgery versus open lobectomy exhibited similar short-term outcomes. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic enhanced recovery protocol.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print
Krebs ED, Mehaffey JH, Sarosiek BM, Blank RS, Lau CL, Martin LW
J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print | PMID: 31610965
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Impact:
Abstract

Long-term, disease-specific outcomes of thymic malignancies presenting with de novo pleural metastasis.

Choe G, Ghanie A, Riely G, Rimner A, ... Jones DR, Huang J
Objective
Treatment of patients with thymic malignancies metastatic to the pleura or pericardium is challenging, and benefits of aggressive treatment are unclear. We sought to characterize the long-term outcomes in this population.
Methods
We retrospectively identified patients who underwent resection for de novo thymic malignancies metastatic to the pleura between May 1997 and December 2017. Patients with pleural recurrence after prior thymectomy were excluded. Patient demographics, perioperative treatments, pathologic findings, and postoperative outcomes were collected. Descriptive statistics and Kaplan-Meier analyses were performed.
Results
Seventy-two patients were included (median age, 51 years [range 25-80]; 36/72 women [50%]). Pathologic diagnosis was thymoma in 57 patients (79%) and thymic carcinoma in 15 patients (21%). Most patients (67/72; 93%) received chemotherapy, radiation, or both. Forty-eight patients underwent thymectomy with pleurectomy, 7 patients underwent extrapleural pneumonectomy, 10 patients underwent thymectomy alone, and 7 patients were unresectable. Macroscopic complete resection was achieved in 52 patients (73%). Five-, 10-, and 15-year overall survivals were 73%, 51%, and 18%, respectively, and median overall survival was 11 years (median follow-up, 5.9 years). Forty-six patients (64%) had disease progression (median time to progression, 2.2 years). Repeat episodes of progression and treatment were common (median, 3 episodes/patient). The longest disease-free interval was 12.4 years. Thirteen patients (18%) remain disease-free; 7 patients (10%) were disease-free for more than 5 years. The longest ongoing survival without progression or reintervention is 9.9 years.
Conclusions
Prolonged survival and, in some cases, cure can be achieved in patients with thymic malignancies metastatic to the pleura or pericardium. Aggressive multimodality therapy may be appropriate for select patients.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print
Choe G, Ghanie A, Riely G, Rimner A, ... Jones DR, Huang J
J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print | PMID: 31610957
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Impact:
Abstract

Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs.

Axtell AL, Moonsamy P, Melnitchouk S, Jassar AS, ... Cameron DE, Sundt TM
Background
There is growing concern over the impact of fatigue and long work hours on patient safety. Our objective was to determine the perioperative outcomes and hospital costs associated with starting nonemergent cardiac surgical cases after 3 pm.
Methods
A retrospective analysis was performed on adult patients who underwent elective coronary artery bypass or valve surgery at our institution between July 2011 and March 2018. Cases were defined as \"late start\" if the incision time was after 3 pm. Postoperative outcomes, 30-day mortality, and total hospital costs were compared between propensity-matched samples of early-starting and late-starting cases.
Results
Of 2463 elective cases, 352 (14%) started after 3 pm. In propensity-matched samples, patients who had a late start demonstrated no difference in 30-day mortality (1% vs <1%; P = .10) or postoperative complications, such as prolonged ventilation (5% vs 7%; P = .37), renal failure (2% vs 1%), or stroke (2% vs 1%; P = .23) compared with patients who had an early start. A late start did not impact the median duration of ventilation (4 vs 5 hours; P = .72), intensive care unit (ICU) length of stay (26 vs 22 hours; P = .28), or postoperative length of stay (6 vs 7 days; P = .37). In addition, there were no significant differences in total hospital cost (P = .09), operating room cost (P = .22), or ICU cost (P = .05).
Conclusions
We report no differences in perioperative outcomes, operative mortality, length of stay, or total hospital cost for elective cases that start after 3 pm. This may be attributable to the resources available at a large quaternary center regardless of time of day.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 10 Sep 2019; epub ahead of print
Axtell AL, Moonsamy P, Melnitchouk S, Jassar AS, ... Cameron DE, Sundt TM
J Thorac Cardiovasc Surg: 10 Sep 2019; epub ahead of print | PMID: 31607496
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Impact:
Abstract

Resection Process Map: A novel dynamic simulation system for pulmonary resection.

Tokuno J, Chen-Yoshikawa TF, Nakao M, Matsuda T, Date H
Objective
Use of 3-dimensional computed tomography for preoperative and intraoperative simulation has been introduced in the field of thoracic surgery. However, 3-dimensional computed tomography provides only static simulation, which is a significant limitation of surgical simulation. Dynamic simulation, reflecting the intraoperative deformation of the lung, has not been developed. The aim of this study was to develop a novel simulation system that generates dynamic images based on patient-specific computed tomography data.
Methods
We developed an original software, the Resection Process Map, for anatomic pulmonary resection. The Resection Process Map semi-automatically generates virtual dynamic images based on patient-specific computed tomography data. We retrospectively evaluated its accuracy in 18 representative cases by comparing the virtual dynamic images with the actual surgical images.
Results
In this study, 9 patients who underwent lobectomy and 9 patients who underwent segmentectomy were included. For each case, a virtual dynamic image was successfully generated semi-automatically by the Resection Process Map. The Resection Process Map accurately delineated 98.6% of vessel branches and all the bronchi. The median time required to obtain the images was 121.3 seconds.
Conclusions
We successfully developed a novel dynamic simulation system, the Resection Process Map, for anatomic pulmonary resection.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print
Tokuno J, Chen-Yoshikawa TF, Nakao M, Matsuda T, Date H
J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print | PMID: 31606178
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Impact:
Abstract

Development of a risk score for early saphenous vein graft failure: An individual patient data meta-analysis.

Antonopoulos AS, Odutayo A, Oikonomou EK, Trivella M, ... Antoniades C,
Objectives
Early saphenous vein graft (SVG) occlusion is typically attributed to technical factors. We aimed at exploring clinical, anatomical, and operative factors associated with the risk of early SVG occlusion (within 12 months postsurgery).
Methods
Published literature in MEDLINE was searched for studies reporting the incidence of early SVG occlusion. Individual patient data (IPD) on early SVG occlusion were used from the SAFINOUS-CABG Consortium. A derivation (n = 1492 patients) and validation (n = 372 patients) cohort were used for model training (with 10-fold cross-validation) and external validation respectively.
Results
In aggregate data meta-analysis (48 studies, 41,530 SVGs) the pooled estimate for early SVG occlusion was 11%. The developed IPD model for early SVG occlusion, which included clinical, anatomical, and operative characteristics (age, sex, dyslipidemia, diabetes mellitus, smoking, serum creatinine, endoscopic vein harvesting, use of complex grafts, grafted target vessel, and number of SVGs), had good performance in the derivation (c-index = 0.744; 95% confidence interval [CI], 0.701-0.774) and validation cohort (c-index = 0.734; 95% CI, 0.659-0.809). Based on this model. we constructed a simplified 12-variable risk score system (SAFINOUS score) with good performance for early SVG occlusion (c-index = 0.700, 95% CI, 0.684-0.716).
Conclusions
From a large international IPD collaboration, we developed a novel risk score to assess the individualized risk for early SVG occlusion. The SAFINOUS risk score could be used to identify patients that are more likely to benefit from aggressive treatment strategies.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Aug 2019; epub ahead of print
Antonopoulos AS, Odutayo A, Oikonomou EK, Trivella M, ... Antoniades C,
J Thorac Cardiovasc Surg: 25 Aug 2019; epub ahead of print | PMID: 31606176
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Impact:
Abstract

Postoperative day 1 discharge after anatomic lung resection: A Society of Thoracic Surgeons database analysis.

Linden PA, Perry Y, Worrell S, Wallace A, ... Ho VP, Towe CW
Objective
Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals.
Methods
We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission.
Results
A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges.
Conclusions
Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print
Linden PA, Perry Y, Worrell S, Wallace A, ... Ho VP, Towe CW
J Thorac Cardiovasc Surg: 12 Sep 2019; epub ahead of print | PMID: 31606175
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Impact:
Abstract

Simultaneous bilateral thoracoscopic blebs excision reduces contralateral recurrence in patients undergoing operation for ipsilateral primary spontaneous pneumothorax.

Liu YW, Chang PC, Chang SJ, Chiang HH, Li HP, Chou SH
Objective
Contralateral recurrence in patients with primary spontaneous pneumothorax is approximately 15%. If positive for blebs, the recurrence rate increases to 26%. This study seeks to determine whether simultaneous contralateral video-assisted thoracic surgery blebs excision would effectively lower the contralateral incidence of pneumothorax in patients undergoing surgery for ipsilateral primary spontaneous pneumothorax.
Methods
Between January 2009 and December 2015, 335 patients with primary spontaneous pneumothorax, surgically treated in a single institution, were retrospectively studied. The median follow-up was 75 (50-99) months. All patients received video-assisted thoracic surgery blebectomy/bullectomy with pleural abrasions. They were classified into 3 groups: (1) ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae included 142 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs/bullae only receiving ipsilateral video-assisted thoracic surgery; (2) ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae included 123 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving only ipsilateral video-assisted thoracic surgery; and (3) bilateral video-assisted thoracic surgery with contralateral blebs/bullae included 70 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving 1-stage bilateral video-assisted thoracic surgery. Demographic data, perioperative details, recurrence patterns, recurrence-free survivals, and risk factors were compared.
Results
The percentage of contralateral recurrence for the ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae, ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae, and bilateral video-assisted thoracic surgery with contralateral blebs/bullae groups differed significantly (0.7%, 14.6%, and 2.9%, respectively; P = .002). Multivariate analysis using the Cox proportional hazard model revealed that age less than 18 years (hazard ratio, 2.71; 95% confidence interval, 1.14-6.44; P = .024) and ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae (hazard ratio, 22.13, 95% confidence interval, 2.96-165, P = .003) were predictors of contralateral recurrence, of which recurrence-free survival was notably different among groups as determined by Kaplan-Meier analysis (P < .0001).
Conclusions
Simultaneous contralateral blebectomy in patients with primary spontaneous pneumothorax receiving ipsilateral video-assisted thoracic surgery significantly lowered future contralateral recurrence.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print
Liu YW, Chang PC, Chang SJ, Chiang HH, Li HP, Chou SH
J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print | PMID: 31606164
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Impact:
Abstract

Complete atrioventricular septal defect repair in Australia: Results over 25 years.

Fong LS, Betts K, Bell D, Konstantinov IE, ... Orr Y,
Objectives
To evaluate whether the long-term outcomes of modified-single-patch (MSP) repair of complete atrioventricular septal defect are equivalent to double-patch (DP) repair with respect to survival and risk of reoperation for left atrioventricular valve regurgitation or left ventricular outflow tract obstruction.
Methods
All patients who underwent biventricular repair of complete atrioventricular septal defect in Australia from 1990 to 2015 using either a MSP or DP technique were identified. Demographic characteristic details, operative data, and outcomes were analyzed. A propensity score analysis was performed to balance the 2 treatment groups according to several baseline covariates. Survival and freedom from reintervention between the 2 groups were compared using Kaplan-Meier curves and log-rank tests.
Results
A total of 819 patients underwent repair of complete atrioventricular septal defect (252 MSP and 567 DP) during the study period. There was no significant difference in unmatched survival (P = .85) and event-free survival (P = .49) between MSP and DP repair. Propensity score matching resulted in a total of 223 matched pairs. Matched analysis found no difference in overall survival (P = .59) or event-free survival (P = .90) between repair techniques, with an estimated event-free survival at 5, 10, and 15 years of 83%, 83%, and 74% for DP and 83%, 80%, and 77% for the MSP group, respectively. There was no significant difference between repair techniques in reoperation for left atrioventricular valve regurgitation or left ventricular outflow tract obstruction or need for permanent pacemaker.
Conclusions
Overall and event free survival are similar following either MSP or DP repair of complete atrioventricular septal defect. There is no increased risk of reoperation for left ventricular outflow tract obstruction with the MSP technique.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Aug 2019; epub ahead of print
Fong LS, Betts K, Bell D, Konstantinov IE, ... Orr Y,
J Thorac Cardiovasc Surg: 29 Aug 2019; epub ahead of print | PMID: 31590953
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Impact:
Abstract

Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis.

Gambardella I, Gaudino MFL, Antoniou GA, Rahouma M, ... Nappi F, Girardi LN
Objective
To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients.
Methods
Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators.
Results
Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P < .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P < .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P < .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P < .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P < .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction.
Conclusions
DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print
Gambardella I, Gaudino MFL, Antoniou GA, Rahouma M, ... Nappi F, Girardi LN
J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print | PMID: 31590948
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Impact:
Abstract

Association between F-18 fluorodeoxyglucose uptake of noncancerous lung area and acute exacerbation of interstitial pneumonia in patients with lung cancer after resection.

Yamamichi T, Shimada Y, Masuno R, Ohira T, ... Yoshimura A, Ikeda N
Background
Idiopathic pulmonary fibrosis is defined as a specific form of progressive fibrosing interstitial pneumonia. Postoperative acute exacerbation is considered a lethal comorbidity for patients with lung cancer, particularly when it is accompanied with idiopathic pulmonary fibrosis. Thus, pretherapeutic risk stratification for acute exacerbation has been anticipated. In this study, we aimed to investigate whether the maximum standardized uptake value of F-18 fluorodeoxyglucose is useful for assessing the postoperative risk of acute exacerbation and severe respiratory adverse events in patients with lung cancer after surgical resection.
Methods
A total of 822 patients with lung cancer who underwent preoperative high-resolution computed tomography, fluorodeoxyglucose-positron emission tomography/computed tomography, and pulmonary resection between July 2012 and July 2018 were assessed. Maximum standardized uptake value of the main tumor and that of the noncancerous lung area were measured using a 3-dimensional workstation. Multivariable analyses for acute exacerbation and severe respiratory adverse events were performed using the logistic regression model.
Results
Among all patients, 120 (14.6%) had idiopathic pulmonary fibrosis findings on high-resolution computed tomography whereas severe respiratory adverse events were observed in 35 (4.2%) patients, including those with acute exacerbation (n = 15, 1.8%). Maximum standardized uptake value of the main tumor and that of the noncancerous lung area were independently associated with both acute exacerbation and severe respiratory adverse events on multivariable analysis, both in all patients and in the 120 patients with idiopathic pulmonary fibrosis. Risk stratification analysis showed that 19.0% and 30.2% of patients who were positive for idiopathic pulmonary fibrosis on high-resolution computed tomography and with a maximum standardized uptake value of the main tumor and that of the noncancerous lung area 1.69 or greater (the optimal cutoff value relevant to acute exacerbation) experienced acute exacerbation and severe respiratory adverse events, respectively.
Conclusions
Maximum standardized uptake value of the main tumor and that of the noncancerous lung area were independently associated with the incidence of postoperative acute exacerbation and severe respiratory adverse events in patients with lung cancer.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Yamamichi T, Shimada Y, Masuno R, Ohira T, ... Yoshimura A, Ikeda N
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31587890
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Impact:
Abstract

Impact of shaggy aorta on outcomes of open thoracoabdominal aortic aneurysm repair.

Yokawa K, Ikeno Y, Henmi S, Yamanaka K, Okada K, Okita Y
Background
The aim of this study was to evaluate the impact of diffuse aortic atherosclerosis-related thrombosis, or \"shaggy aorta\" on the outcomes of open thoracoabdominal aortic aneurysm repair (TAAA).
Methods
From October 1999 to March 2018, 251 patients underwent open TAAA repair using segmental-staged aortic clamping. Twenty-eight patients (11.2%) received emergent or urgent operations. Patients were classified into 3 groups: dissection aneurysm (139 patients, 55.4%), degenerative aneurysm without shaggy aorta (76 patients, 30.3%), and degenerative aneurysm with shaggy aorta (36 patients, 14.3%). Shaggy aorta was assessed using enhanced computed tomography and defined as patients with atheroma thickness ≥5 mm with irregular atheroma surface. Mean follow-up was 4.3 ± 4.1 years.
Results
Operative mortality was 8% (20 patients) and spinal cord injury occurred in 25 patients (10.0%), 16 of whom (6.4%) had permanent neurologic dysfunction. Operative mortality was significantly worse in patients with shaggy aorta (dissection: 2.2%, non-shaggy: 6.6%, and shaggy: 33.3%, P < .001) and shaggy aorta was a significant risk factor for spinal cord injury (dissection: 7.2%, non-shaggy: 6.6%, and shaggy: 27.8%, P < .003). Multivariable analysis demonstrated that shaggy aorta was a significant risk factor for composite outcome consisted of operative mortality, spinal cord injury, and acute renal failure (odds ratio, 4.78; 95% confidence interval, 1.91-12.3, P < .001).
Conclusions
Preoperative enhanced computed tomography assessment of shaggy aorta could predict high-risk patients for open TAAA repair.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print
Yokawa K, Ikeno Y, Henmi S, Yamanaka K, Okada K, Okita Y
J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print | PMID: 31587889
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Abstract

Impact of fundoplication for gastroesophageal reflux in the outcome of benign tracheal stenosis.

Bianchi ET, Guerreiro Cardoso PF, Minamoto H, Bibas BJ, ... Pego-Fernandes PM,
Objective
This study focuses on the impact of antireflux surgery in the outcome of tracheal stenosis.
Methods
We performed a retrospective study including patients with benign tracheal stenosis who underwent esophageal manometry and dual-probe 24-hour ambulatory esophageal pH study. Patients with an abnormal pH study were managed with laparoscopic modified Nissen fundoplication or medically (omeprazole 80 mg/d, orally). Patients with normal pH study results were observed. After a 24-month follow-up, the outcome was considered satisfactory if tracheal stenosis could be managed by resection and there was no need for further dilatation or definitive decannulation. The management groups were compared using propensity score matching.
Results
A total of 175 patients were included. Abnormal pH study results were found in 74 patients (42.3%), and 12.6% of patients had typical gastroesophageal reflux symptoms. Follow-up was completed in 124 patients (20 had fundoplication, 32 received omeprazole, and 72 were observed). After propensity score matching, the outcome of tracheal stenosis in the fundoplication group was similar to that of the observation group (odds ratio, 1; P = .99) and better than that of the omeprazole group (odds ratio, 5.31; P = .03). The observation (no gastroesophageal reflux) group had a better outcome of stenosis than those treated with omeprazole (odds ratio, 3.54; P = .02).
Conclusions
The outcome of the airway stenosis was superior after laparoscopic fundoplication compared with medical treatment with omeprazole and was similar to the outcome of patients without gastroesophageal reflux. A prospective randomized trial is warranted.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print
Bianchi ET, Guerreiro Cardoso PF, Minamoto H, Bibas BJ, ... Pego-Fernandes PM,
J Thorac Cardiovasc Surg: 04 Sep 2019; epub ahead of print | PMID: 31587887
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Impact:
Abstract

Is previous cardiac surgery a risk factor for open repair of acute type A aortic dissection?

Norton EL, Rosati CM, Kim KM, Wu X, ... Deeb GM, Yang B
Objective
The study objective was to determine the optimal treatment for patients with acute type A aortic dissection and previous cardiac surgery.
Methods
A total of 545 patients underwent open repair of an acute type A aortic dissection (July 1996 to January 2017), including patients with (n = 50) and without previous cardiac surgery (n = 495). Data were collected through the University of Michigan Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.
Results
Compared with patients without previous cardiac surgery, patients with previous cardiac surgery were older (62 vs 59 years, P = .24) and had significantly more coronary artery disease (48% vs 14%, P < .001), peripheral arterial disease (24% vs 11%, P = .01), connective tissue disorders (15% vs 4.5%, P = .004), and acute renal failure on presentation (28% vs 15%, P = .02); and significantly more concomitant mitral or tricuspid procedures, longer cardiopulmonary bypass time, and more intraoperative blood transfusions. There were no statistically significant differences in postoperative major complications between previous cardiac surgery and no previous cardiac surgery groups, including stroke, myocardial infarction, new-onset dialysis, and 30-day mortality (8.9% vs 6.3%, P = .55). Multivariable logistic model showed the significant risk factors for operative mortality were cardiogenic shock (odds ratio, 9.6; P < .0001) and male gender (odds ratio, 3.7; P = .006). The 5- and 10-year unadjusted survivals were significantly lower in the previous cardiac surgery group compared with the no previous cardiac surgery group (66% vs 80% and 42% vs 66%, respectively, P = .02). However, previous cardiac surgery itself was not a significant risk factor for operative mortality (odds ratio, 1.6; P = .36) or all-time mortality (hazard ratio, 1.3; P = .33).
Conclusions
Acute type A aortic dissection in patients with previous cardiac surgery can be repaired with favorable operative mortality and long-term survival, and should be treated surgically.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Norton EL, Rosati CM, Kim KM, Wu X, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31585754
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Abstract

Implementation of a specific safety check is associated with lower postoperative mortality in cardiac surgery.

Spanjersberg AJ, Ottervanger JP, Nierich AP, Speekenbrink RGH, ... Houterman S, Brandon Bravo Bruinsma GJ
Introduction
In cardiac surgery, a preincision safety checklist may decrease complications and improve survival. Until now, it has not been demonstrated whether the implementation of such a checklist indeed reduces mortality.
Objective
Introduction of a preincision safety checklist on mortality was studied in a large adult cardiac surgery population.
Methods
This prospective, multicenter cohort study included 5937 consecutive adult patients, undergoing cardiac surgery, between January 2015 and December 2015, in 7 Dutch non-academic cardiac centers. The Isala Safety Check (ISC) is a short checklist addressing specific cardiac surgery safety items, in combination with a concise postinduction transesophageal echocardiography, which was gradually over time introduced in the 7 hospitals during 2015. We compared 120-day mortality and major complications between patients undergoing surgery with or without the use of the ISC. Propensity matching and Cox regression analyses were performed to adjust for potential confounders.
Results
The ISC was applied in 2718 patients (46%). Comorbidity and age were comparable in both groups. In the ISC group, 120-day mortality was significantly lower (1.7% vs 3.0%; P < .01). Both after propensity matching (hazard ratio, 0.44; 95% confidence interval, 0.22-0.87) and Cox regression analysis (hazard ratio, 0.56; 95% confidence interval, 0.35-0.90), the use of the ISC was still associated with reduced 120-day mortality. Deep sternal wound infection, surgical re-exploration, and stroke were not significantly different between both groups.
Conclusions
Application of a short preincision safety checklist in a mixed population of adult cardiac surgery patients is associated with significantly reduced 120-day mortality.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Spanjersberg AJ, Ottervanger JP, Nierich AP, Speekenbrink RGH, ... Houterman S, Brandon Bravo Bruinsma GJ
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31582206
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Impact:
Abstract

Cavopulmonary assist: Long-term reversal of the Fontan paradox.

Rodefeld MD, Marsden A, Figliola R, Jonas T, Neary M, Giridharan GA
Objective
Fontan circulatory inefficiency can be addressed by replacing the missing subpulmonary power source to reverse the Fontan paradox. An implantable cavopulmonary assist device is described that will simultaneously reduce systemic venous pressure and increase pulmonary arterial pressure, improving preload and cardiac output, in a univentricular Fontan circulation on a long-term basis.
Methods
A rotary blood pump that was based on the von Karman viscous pump was designed for implantation into the total cavopulmonary connection (TCPC). It will impart modest pressure energy to augment Fontan flow without risk of obstruction. In the event of rotational failure, it is designed to default to a passive flow diverter. Pressure-flow performance was characterized in vitro in a Fontan mock circulatory loop with blood analog.
Results
The pump performed through the fully specified operating range, augmenting flow in all 4 directions of the TCPC. Pressure rise of 6 to 8 mm Hg was readily achieved, ranging to 14 mm Hg at highest speed (5600 rpm). Performance was consistent across a wide range of cardiac outputs. In stalled condition (0 rpm), there was no discernible pressure loss across the TCPC.
Conclusions
A blood pump technology is described that can reverse the Fontan paradox and may permit a surgical strategy of long-term biventricular maintenance of a univentricular Fontan circulation. The technology is intended for Fontan failure in which right-sided circulatory inefficiencies predominate and ventricular systolic function is preserved. It may also apply before clinical Fontan failure as health maintenance to preempt the progression of Fontan disease.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Rodefeld MD, Marsden A, Figliola R, Jonas T, Neary M, Giridharan GA
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31564543
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Impact:
Abstract

Handmade fenestrated stent grafts to preserve all supra-aortic branches in thoracic endovascular aortic repair.

Kuo HS, Huang JH, Chen JS
Objective
To evaluate the efficacy and safety of a zone 0 landing aortic stent graft with handmade fenestrations for the preservation of all supra-aortic branches in thoracic endovascular aortic repair (TEVAR).
Methods
This study included 13 consecutive patients who underwent TEVAR using zone 0 landing handmade fenestrated stent grafts to preserve all supra-aortic branches from July 2016 to April 2017. Technical success was defined as the resolution of the primary aortic pathology as well as the preservation of all supra-aortic branches through the accurate alignment of the fenestration. Outcomes including technical success, perioperative morbidity and mortality, requirement of secondary interventions, and graft patency were analyzed.
Results
In this study, 11 patients presented with aortic dissection, 1 presented with thoracic aortic aneurysm with impending rupture, and 1 presented with penetrating aortic ulcer of the thoracic aorta. The technical success rate of the primary procedure was 100%. Over a mean follow-up of 20 months, secondary endovascular procedures were performed in 6 patients to resolve 3 cases of stent graft-induced new entry, 2 cases of type Ib endoleak, and 1 case of new false lumen formation. During the study period, no complication resulting from proximal landing and fenestration occurred.
Conclusions
Our experience of using handmade fenestrated stent grafts revealed preliminary results of using the grafts to preserve all supra-aortic branches in TEVAR, and results demonstrated the feasibility of this technique for achieving total arch replacement endovascularly in selective patients. Further technical advancement is anticipated, and larger studies with long-term follow-up are required.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print
Kuo HS, Huang JH, Chen JS
J Thorac Cardiovasc Surg: 27 Aug 2019; epub ahead of print | PMID: 31564542
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Impact:
Abstract

Biventricular repair of double-outlet right ventricle with noncommitted ventricular septal defect using intraventricular conduit.

Lu T, Li J, Hu J, Huang C, ... Wu Q, Wu Z
Objective
Biventricular repair of double-outlet right ventricle with noncommitted ventricular septal defect is preferred, but previously developed surgical procedures are complicated and associated with high mortality and morbidity. We developed a technique using an intraventricular conduit to connect the ventricular septal defect and the aorta in this anomaly in patients aged more than 2 years.
Methods
Thirty-one patients (age 2-23 years; median, 5.4) with double-outlet right ventricle with noncommitted ventricular septal defect underwent biventricular repair with intraventricular conduit. A 16-mm or 19-mm polytetrafluoroethylene (Gore-Tex; WL Gore & Associates, Flagstaff, Ariz) vascular prosthesis was used to construct the intraventricular conduit rerouting the ventricular septal defect to the aorta, with enlargement of the ventricular septal defect and resecting the hypertrophic muscular bands in the bilateral conus when necessary. Follow-up was made in all patients with a median duration of 93 months (range, 8-140 months).
Results
One patient died during hospitalization and 1 patient died at 8 months after operation, making the mortality 6.5%. The peak pressure gradient across the left ventricular outflow tract was less than 30 mm Hg in all patients but 1 (3.3%). In the last patient, it increased from 16 mm Hg early after operation to 50 mm Hg at 7 years follow-up. The peak pressure gradient across the right ventricular outflow tract ranged from 6 to 30 mm Hg in all patients. One patient had moderate mitral regurgitation with New York Heart Association class II. One patient had preoperative severe pulmonary arterial hypertension (mean pressure, 50 mm Hg) and was treated with bosentan. Other patients were in New York Heart Association class I.
Conclusions
Biventricular repair with intraventricular conduit is a relatively simple and safe procedure for patients aged more than 2 years with double-outlet right ventricle with noncommitted ventricular septal defect, with excellent early and midterm outcomes.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 23 Aug 2019; epub ahead of print
Lu T, Li J, Hu J, Huang C, ... Wu Q, Wu Z
J Thorac Cardiovasc Surg: 23 Aug 2019; epub ahead of print | PMID: 31564538
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Impact:
Abstract

Mitral regurgitation worsens cardiac remodeling in ischemic cardiomyopathy in an experimental model.

Onohara D, Corporan D, Hernandez-Merlo R, Guyton RA, Padala M
Objective
Mitral regurgitation (MR) developing concomitant with ischemic cardiomyopathy is a frequently diagnosed valvular lesion, for which an optimal therapeutic strategy is unknown. The contribution of MR to the ongoing cardiac remodeling from myocardial infarction (MI) remains controversial. We have developed a novel experimental model in which MI and severe MR can be independently introduced, to study the role of MR in chronic remodeling of the ischemic heart.
Methods
A total of 98 rats were induced with MI+MR (group 1), MI (group 2), MR (group 3), or sham surgery (group 4). MR was induced by inserting a needle into the anterior mitral leaflet via the ventricular apex in a beating heart. MI was induced by ligating the left coronary artery. Biweekly ultrasound examinations were performed after surgery, and invasive hemodynamic assessments were performed in some rats at 2, 10, and 20 weeks.
Results
At 2 weeks postsurgery, the mean end-diastolic volume was 432 ± 103 μL in ischemic hearts with MR, compared with 390 ± 76.3 μL in ischemic hearts without MR (a 10.76% difference). By 20 weeks, the mean volume was significantly greater in the former group (767 ± 246 μL vs 580 ± 85 μL; a 32.24% difference). At 2 weeks, mean end-systolic volume was 147 ± 46.8 μL in the ischemic hearts with MR and 147 ± 45.7 μL in those without MR. By 20 weeks, the mean volumes had increased to 357 ± 136.4 μL and 271 ± 82.3 μL, respectively (a 31.73% difference).
Conclusions
MR in ischemic hearts significantly increased end-diastolic and end-systolic volumes of the left ventricle, indicating adverse cardiac remodeling and worse systolic function.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Onohara D, Corporan D, Hernandez-Merlo R, Guyton RA, Padala M
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31562015
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Impact:
Abstract

Total arch replacement in octogenarians and nonagenarians: A single-center 18-year experience.

Ikeno Y, Yokawa K, Yamanaka K, Inoue T, ... Okada K, Okita Y
Background
This study evaluates our 18-year experience of total arch replacement in the octogenarian and nonagenarian population.
Methods
Between October 1999 and March 2018, a total of 740 patients underwent total arch replacement at our institution. A total of 139 patients were aged 80 years or more (83.1 ± 2.8 years), and 601 patients were aged less than 80 years (66.9 ± 11.3 years). Early and late outcomes were compared between the groups.
Results
In the group aged 80 years or more, operative mortality occurred in 12 patients (8.6%) and significantly improved over time (P = .010). Operative mortality was significantly higher in the group aged 80 years or more (P = .033) when compared with the group aged less than 80 years (4.0%). Regarding postoperative complications, deep sternal wound infection, pneumonia, and tracheostomy occurred in significantly more patients in the group aged 80 years or more. In the group aged 80 years or more, there were 52 late deaths, with 4 aortic-related deaths. Overall survival was 55.4% ± 5.0% at 5 years and 32.2% ± 6.1% at 8 years. Multivariable Cox-hazard regression analysis demonstrated that chronic kidney disease, nonelective surgery, and concurrent procedures were significant risk factors for overall survival in the group aged 80 years or more. Cumulative incidence for reoperation was significantly lower in the group aged 80 years or more (8.7% at 5 years) compared with the group aged less than 80 years (14.2% at 5 years).
Conclusions
Total arch replacement was performed with an acceptable overall survival in octogenarians and nonagenarians, although operative mortality was higher than in younger patients. However, older patients had a lesser burden of reoperation compared with younger patients.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Ikeno Y, Yokawa K, Yamanaka K, Inoue T, ... Okada K, Okita Y
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31562010
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Impact:
Abstract

Predictor of false lumen thrombosis after thoracic endovascular aortic repair for type B dissection.

Li D, Peng L, Wang Y, Zhao J, Yuan D, Zheng T
Objective
Thoracic endovascular aortic repair of type B aortic dissection initiates thrombosis in the false lumen, which eventually results in aortic remodeling. We aimed to determine whether the false lumen thrombosis rate (FLTR) after thoracic endovascular aortic repair can be accurately predicted by an index that expresses the degree of aortic arch angulation.
Methods
The geometry of 48 patients with acute type B aortic dissection (mean age, 48 years) after thoracic endovascular aortic repair was reconstructed from postoperative computed tomography images. We introduced a novel angle-the degree of question mark (φ)-to indicate the aortic morphology. Moreover, how aortic angulation influenced the FLTR was investigated based on hemodynamic parameters. Finally, a predicted mathematical model relating FLTR to aortic angulation was proposed, and 10 patients were chosen to validate the model.
Results
The degree of question mark shape was shown to negatively correlate with FLTR (n = 38; P < .001; R = -0.661), and the linear relationship model was created as follows: FLTR (%) = -1.955 × φ + 168.24 (R = 0.437; P < .001). In addition, the net flow rate to the false lumen significantly increased with the increase of the degree of the question mark shape of the aorta. Furthermore, the difference and concordance of the proposed prediction model were perfectly validated in the remaining 10 patients using paired-sample t test and the concordance correlation coefficient.
Conclusions
The size of the question mark shape may be a good predictor for FLTR of acute type B aortic dissection following thoracic endovascular aortic repair. The higher the degrees of the question mark, the less likely it was to form a complete thrombus.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Li D, Peng L, Wang Y, Zhao J, Yuan D, Zheng T
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31558276
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Impact:
Abstract

Outcomes of marginal donors for lung transplantation after ex vivo lung perfusion: A systematic review and meta-analysis.

Tian D, Wang Y, Shiiya H, Sun CB, ... Sato M, Nakajima J
Objective
Ex vivo lung perfusion (EVLP) is reportedly a useful strategy that permits marginal donor lungs to be evaluated and reconditioned for successful lung transplantation (LTx). This systematic review and meta-analysis was performed to evaluate the outcomes of EVLP conducted for marginal donor lungs.
Methods
We searched PubMed, the Cochrane Library, and Embase to select studies describing the results of LTx following EVLP for marginal donor lungs compared with standard LTx without EVLP. We performed a meta-analysis to examine donor baseline characteristics, recipient baseline characteristics, and postoperative outcomes.
Results
Of 1380 studies, 8 studies involving 1191 patients met the inclusion criteria. Compared with the non-EVLP group (ie, standard LTx without EVLP), the EVLP group (ie, EVLP of marginal donors following LTx) had similar donor age and sex and recipient baseline age, sex, body mass index, bridge by ventilator/extracorporeal life support/extracorporeal membrane oxygenation, and rate of double LTx but more abnormal donor lung radiographs (P = .0002), a higher smoking history rate (P = .03), and worse donor arterial oxygen tension/inspired oxygen fraction (P < .00001). However, there were no significant differences in outcomes between the EVLP and non-EVLP groups with respect to the length of postoperative intubation, postoperative extracorporeal life support/extracorporeal membrane oxygenation use, length of intensive care unit stay, length of hospital stay, 72-hour primary graft dysfunction of grade 3, 30-day survival, or 1-year survival (all P values > .05).
Conclusions
Posttransplant outcomes were similar between EVLP-treated LTx and standard LTx without EVLP, although the quality of donor lungs was worse with EVLP-treated LTx.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Tian D, Wang Y, Shiiya H, Sun CB, ... Sato M, Nakajima J
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31548078
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Impact:
Abstract

Entire mitral reconstruction with porcine extracellular matrix in an acute porcine model.

Tjørnild MJ, Carlson Hanse L, Skov SN, Poulsen KB, ... Nielsen SL, Hasenkam JM
Objective
The objective of our study was to investigate the feasibility of reconstructing the entire mitral valvular and subvalvular apparatus in pigs using a modified tube graft design made of 2-ply small intestinal submucosa extracellular matrix.
Methods
The reconstructions were performed in an acute 80-kg porcine model with 8 pigs, each acting as its own control. A modified tube graft was designed from a sheet of 2-ply small intestinal submucosa extracellular matrix. Before and after mitral valve reconstruction, echocardiography was used to assess mitral regurgitation, left ventricular outflow tract obstruction due to systolic anterior motion, mitral stenosis, leaflet mobility, and leaflet geometry.
Results
The reconstructed mitral valves were fully functional without any observable echocardiographic signs of regurgitation. We did not observe any left ventricular outflow tract obstruction due to systolic anterior motion nor any mitral valve stenosis, despite a diminished septal-lateral distance after reconstruction. The reconstruction had a reduced tenting area, a reduced coaptation length (9.6 ± 1.7 mm vs 7.9 ± 1.0 mm, P = .010, diff = -1.7 mm, 95% confidence interval, -3.1 to -0.4 mm), and atrial bending of both leaflets.
Conclusions
In this acute porcine study, entire mitral valvular and subvalvular apparatus reconstruction using a modified tube graft design made from 2-ply small intestinal submucosal extracellular matrix was feasible. The 2-ply small intestinal submucosa extracellular matrix could withstand the pressure exerted by the left ventricle without any signs of tearing or rupture. These promising results warrant further assessment of both the annular geometry and the long-term durability.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Tjørnild MJ, Carlson Hanse L, Skov SN, Poulsen KB, ... Nielsen SL, Hasenkam JM
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31548077
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Impact:
Abstract

Spinal cord collateral flow during antegrade cerebral perfusion for aortic arch surgery.

Kinoshita T, Yoshida H, Hachiro K, Suzuki T, Asai T
Objective
We aimed to monitor regional oxygen saturation levels using near-infrared spectroscopy in patients undergoing total aortic arch replacement and to determine the range of collateral flow via antegrade cerebral perfusion to the spinal cord during lower body circulatory arrest.
Methods
Eighteen consecutive patients undergoing total aortic arch replacement in our hospital were prospectively enrolled. Optodes of near-infrared spectroscopy were attached to the skin at the right and left forehead, and above the paravertebral muscles at the level of the third (T3) and tenth (T10) thoracic vertebra. Within- and between-group differences were compared using mixed-effect model repeated-measures analysis.
Results
Regional oxygen saturation levels, which had been rapidly declining immediately after circulatory arrest at a tympanic temperature of <25°C and a core temperature of <30°C, showed a rapid increase at the forehead with the initiation of antegrade cerebral perfusion (total flow rate 0.81 ± 0.08 L/min, perfusion pressure 37 ± 6 mm Hg, temperature 25°C). Saturation levels remained only partially elevated at the upper thoracic level (T3) and continued to decline without showing signs of recovery at the lower thoracic level (T10).
Conclusions
Antegrade cerebral perfusion partially perfused the upper thoracic cord via collateral circulation from vertebral arteries through an anterior spinal artery, but it did not reach the lower thoracic cord sufficiently to change the oxygenation level. Cooling is a more important means of protection for the lower spinal cord during lower body circulatory arrest than is antegrade cerebral perfusion.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print
Kinoshita T, Yoshida H, Hachiro K, Suzuki T, Asai T
J Thorac Cardiovasc Surg: 24 Aug 2019; epub ahead of print | PMID: 31543306
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Impact:
Abstract

Surgical repair of bicuspid aortopathy at small diameters: Clinical and institutional factors.

Nissen AP, Thanh Truong VT, Alhafez BA, Puthumana JJ, ... ,
Objective
Bicuspid aortic valve is a common risk factor for thoracic aortic aneurysm and dissection. Guidelines for elective ascending aortic intervention (AAI) in bicuspid aortic valve are derived from limited evidence, and the extent of practice variation due to patient and provider characteristics is unknown. Using data from 2 large cardiovascular registries, we investigated factors that influence decisions for AAI.
Methods
All bicuspid aortic valve cases with known aortic diameters and surgical status were included. We used multivariable logistic regression to profile predictors of isolated aortic valve replacement (AVR) or AVR+AAI, stratified by patient characteristics, surgical indications, and institution.
Results
We studied 2861 subjects at 18 institutions from 1996 to 2015. The median aortic diameter of patients who underwent AVR+AAI varied widely across institutions (39-52 mm). Aortic diameters were <45 mm in 38% of patients undergoing AVR+AAI. Patients who underwent AAI at <45 mm, compared with those managed nonoperatively, were younger (54 ± 13 vs 61 ± 15 years; P < .001) with more frequent aortic stenosis (53% vs 28%; P < .001) and regurgitation (52% vs 18%; P < .001).
Conclusions
Clinical and institutional factors influence the timing of AAI and are associated with significant variability in ascending aortic diameter at AAI across institutions. More than one third of patients with a bicuspid aortic valve undergo AAI at aortic diameters <45 mm. Long-term outcomes of this subgroup of patients, who may manifest earlier and more severe disease, are needed to determine the risk-benefit ratio of routine aortic interventions at smaller diameters.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print
Nissen AP, Thanh Truong VT, Alhafez BA, Puthumana JJ, ... ,
J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print | PMID: 31543305
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Impact:
Abstract

Return to intended oncologic treatment after surgery for malignant pleural mesothelioma.

Nelson DB, Rice DC, Mitchell KG, Tsao AS, ... Sepesi B, Mehran RJ
Objective
Trimodality therapy may prolong survival for patients with resectable malignant pleural mesothelioma. However, many patients are unable to complete therapy. We sought to identify risk factors for failing to complete adjuvant intensity-modulated radiation therapy after cytoreduction for malignant pleural mesothelioma.
Methods
We performed a single-institution review of those who received an extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma from 2004 to 2017. Multivariable logistic regression was used to assess preoperative or intraoperative risk factors associated with failing to complete adjuvant intensity-modulated radiation therapy.
Results
A total of 160 patients were identified, among whom 94 (59%) received an extrapleural pneumonectomy and 66 (41%) received a pleurectomy/decortication. Adjuvant intensity-modulated radiation therapy was completed among 105 patients (66%). Reasons for failing to complete adjuvant intensity-modulated radiation therapy included mortality (19), dose constraints (21), postoperative morbidity or delayed recovery (11), and refused or unknown status (4). On multivariable analysis, American Society of Anesthesiologists 3+ classification (P = .002) and smoking history (P = .022) were associated with failure to complete adjuvant intensity-modulated radiation therapy, whereas forced expiratory volume in 1 second 70% or less of predicted and pStage 4 (T4) were significant on univariable analysis only. Other factors, including extrapleural pneumonectomy or pleurectomy/decortication, margin status, age, and histology, were not associated with receiving adjuvant intensity-modulated radiation therapy.
Conclusions
Many patients are unable to complete adjuvant intensity-modulated radiation therapy after cytoreduction. Failure to complete adjuvant intensity-modulated radiation therapy was associated with worse preoperative comorbidity, but not the type of surgery or margin status.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 30 Aug 2019; 158:924-929
Nelson DB, Rice DC, Mitchell KG, Tsao AS, ... Sepesi B, Mehran RJ
J Thorac Cardiovasc Surg: 30 Aug 2019; 158:924-929 | PMID: 31430846
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Impact:
Abstract

The Thoracic Surgery Social Media Network: Early experience and lessons learned.

Luc JGY, Ouzounian M, Bender EM, Blitz A, ... Cooke DT, Antonoff MB
Background
The Thoracic Surgery Social Media Network (TSSMN) is a social media collaborative formed in 2015 by The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery to bring social media attention to key publications from both journals and to highlight major accomplishments in the specialty. Our aim is to describe TSSMN\'s preliminary experience and lessons learned.
Methods
Twitter analytics was used to obtain information regarding the @TSSMN Twitter handle and #TSSMN hashtag. TweetChat and general hashtag #TSSMN analytics were measured using Symplur (Symplur LLC, Los Angeles, Calif). A TSSMN Tweeter App was created, and its use and downloads were analyzed.
Results
Hashtag #TSSMN has a total of 17,181 tweets, 2100 users, and 32,226,280 impressions, with peaks in tweeting activity corresponding to TweetChats. Thirteen 1-hour TweetChats drew a total of 489 participants, 5195 total tweets, and 17,297,708 total impressions. The top demographic category of TweetChat participants included Doctors (47%), Advocates/Supports (11%), and Unknown (10%), with 3% characterized as patients. The TSSMN Tweeter iTunes App (Apple, Cupertino, Calif) was downloaded 3319 times with global representation. A total of 859 articles were viewed through the App, with 450 articles from The Annals of Thoracic Surgery and 409 from The Journal of Thoracic and Cardiovascular Surgery.
Conclusions
We demonstrate that TSSMN further enhances the ability for the journals to connect with their readership and the cardiothoracic community. Ongoing studies to correlate social media attention with article reads, article-level metrics, citations, and journal impact factor are eagerly awaited.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 29 Sep 2019; 158:1127-1136
Luc JGY, Ouzounian M, Bender EM, Blitz A, ... Cooke DT, Antonoff MB
J Thorac Cardiovasc Surg: 29 Sep 2019; 158:1127-1136 | PMID: 31422854
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Impact:
Abstract

Medical student perceptions of a career in cardiothoracic surgery: Results of an institutional survey.

Coyan GN, Kilic A, Gleason TG, Schuchert MJ, ... Kinnunen A, Sultan I
Objectives
Recruiting medical students to cardiothoracic surgery is critical given new training paradigms and projected cardiothoracic surgeon shortages. This study characterizes current perceptions and exposure to cardiothoracic surgery among all levels of medical students.
Methods
Currently active medical students at all levels at a US allopathic medical school were sent an invitation to complete an online survey. Baseline demographics, medical specialty interest, interest and exposure to cardiac surgery specifically, and awareness of procedures performed by cardiothoracic surgeons were evaluated. Five-point Likert scales were used to evaluate attitudes toward facets of the field of cardiothoracic surgery. Only complete surveys over the 4-week enrollment period were used for analysis.
Results
There were 126 surveys (22%) completed during the study period. Interest in cardiothoracic surgery at any point was indicated by 37% of students, but only 13% indicated an interest at the time of the survey. Interest among first-year students was greater than all other classes (30% vs <15%, P = .02). Lifestyle factors and personal attributes of cardiothoracic surgeons were noted as negative factors influencing cardiothoracic surgery perception, whereas intellectual challenge and clinical impact were cited as positive factors. Increasing interaction with faculty/residents and simulation experiences were factors noted to increase interest in the field.
Conclusions
Although medical students report early interest in cardiothoracic surgery because of intellectual stimulation and patient care attributes, lack of early exposure and perceived poor lifestyle negatively affect interest in the field. Early interaction between students and cardiothoracic faculty/trainees along with early exposure opportunities may increase recruitment.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Jul 2019; epub ahead of print
Coyan GN, Kilic A, Gleason TG, Schuchert MJ, ... Kinnunen A, Sultan I
J Thorac Cardiovasc Surg: 24 Jul 2019; epub ahead of print | PMID: 31471086
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Impact:
Abstract

Blood trauma potential of the HeartWare Ventricular Assist Device in pediatric patients.

Granegger M, Thamsen B, Schlöglhofer T, Lach S, ... Hübler M, Zimpfer D
Objective
Mechanical circulatory support has become a standard therapy for adult patients with end-stage heart failure. For pediatric patients, technologic development lags behind with no currently approved implantable rotary blood pump. As an alternative, the HeartWare Ventricular Assist Device (Medtronic, Minneapolis, Minn), originally designed for adults, is increasingly used in pediatric patients. The aim of this multicenter study was to assess in silico, in vitro, and in vivo the blood trauma potential of this pump in pediatric application.
Methods
Clinical outcome and indicators for in vivo blood trauma were investigated retrospectively in 14 pediatric patients with the HeartWare Ventricular Assist Device (age 11.3 ± 4.8 years). Blood trauma mechanisms of the HeartWare Ventricular Assist Device were examined in silico and in vitro at an adult and pediatric operating point (5 L/min and 2.5 L/min at 2800 rpm and 2200 rpm, respectively). The flow was simulated by computational fluid dynamics and analyzed regarding flow structures, shear stresses, and washout. Hemolysis was assessed with pumps circulating bovine blood in a temperate flow circuit.
Results
In the retrospective in vivo analysis, lactate dehydrogenase and D-dimer values were 1.5- and 3-fold elevated, respectively, compared with adult patients with the HeartWare Ventricular Assist Device. Major bleedings were observed in 42.9%, and suspected pump thrombosis and neurologic dysfunction were observed in 14.3% of all patients. In the pediatric conditions, simulations predicted elevated mechanical stress profile below 50 Pa, more stagnant flow field, and longer washout times within the pump. In vitro measurements revealed an increased normalized index of hemolysis (17.5 vs 8.2 mg/100 L; P = .0021).
Conclusions
The HeartWare Ventricular Assist Device, operated at lower speeds and flows, induces elevated blood trauma. Further studies are required to assess the clinical implications of these findings.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 18 Jul 2019; epub ahead of print
Granegger M, Thamsen B, Schlöglhofer T, Lach S, ... Hübler M, Zimpfer D
J Thorac Cardiovasc Surg: 18 Jul 2019; epub ahead of print | PMID: 31444074
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Impact:
Abstract

Prevalence of atrial fibrillation before cardiac surgery and factors associated with concomitant ablation.

McCarthy PM, Davidson CJ, Kruse J, Lerner DJ, ... Elmouelhi AM, Ferguson MA
Objective
Surgical ablation for atrial fibrillation concomitant with cardiac surgery is now a Class I recommendation for selected patients. Understanding how the revised recommendations will affect appropriate use of surgical ablation is challenging because the reported prevalence of preoperative atrial fibrillation depends on the definition used. The objective was to determine the prevalence of atrial fibrillation in the 3 years before cardiac surgery and the rate of concomitant surgical ablation.
Methods
Patients with and without a diagnosis of atrial fibrillation in the 3 years before surgical coronary artery bypass, aortic valve replacement, or mitral valve replacement/repair were identified in the 2014 Medicare Standard Analytical File.
Results
Patients had prior atrial fibrillation in 28.4% of 79,134 cardiac surgeries. Prior atrial fibrillation was associated with risk factors for increased cardiac surgical morbidity/mortality, including recent heart failure, renal failure, and lung disease. Black patients were less likely to have prior atrial fibrillation but more likely to have had infrequent care for it. Isolated coronary artery bypass had the lowest prevalence but highest absolute number of prior atrial fibrillation cases. Concomitant surgical ablation was performed in 22.1% of patients with prior atrial fibrillation. Patients with mitral valve surgery were 3-fold more likely to receive surgical ablation. Women were less likely to have prior atrial fibrillation but less likely to have surgical ablation when they did.
Conclusions
Medicare beneficiaries had a substantially higher prevalence of atrial fibrillation diagnoses in the 3 years before cardiac surgery than previously published rates of preoperative atrial fibrillation. Concomitant surgical ablation was performed in less than one-quarter of patients with atrial fibrillation undergoing cardiac surgery for other indications.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print
McCarthy PM, Davidson CJ, Kruse J, Lerner DJ, ... Elmouelhi AM, Ferguson MA
J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print | PMID: 31444073
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Impact:
Abstract

Left ventricular dysfunction in potential heart donors and its influence on recipient outcomes.

Oras J, Doueh R, Norberg E, Redfors B, Omerovic E, Dellgren G
Objectives
New onset of left ventricular (LV) dysfunction in organ donors is frequent and considered as a contraindication for utilization of the heart. However, such dysfunction might be caused by sympathetic stress and could be transient (Takotsubo syndrome). In this study, we assessed the incidence, pattern, and predictors of LV dysfunction in potential heart donors and evaluated its influence on recipient outcomes.
Methods
Donor records of consecutive organ donors in western Sweden between 2006 and 2016 were reviewed. Recipients of transplanted donor hearts were identified in the Scandiatransplant database.
Results
Of 641 potential heart donors who underwent echocardiographic assessment, LV dysfunction (ejection fraction <50% and/or regional hypokinesia) was found in 155 donors (24%). Regional hypokinesia was seen in 113 donors of whom 46 had a Takotsubo-like circumferential hypokinetic pattern. Independent donor variables associated with LV dysfunction were a younger age, cardiac arrest as a contributing factor to death, need for inotropic support, and a shorter time from admission to declaration of brain death. A total of 338 (54%) donor hearts were transplanted, of which 45 (14%) had LV dysfunction. LV dysfunction was a major determinant of not transplanting the heart (P < .001). After transplantation, LV function normalized in the recipients. Neither short-term outcomes nor the composite end point of death or retransplantation over time differed between recipients of donor hearts with versus without LV dysfunction (P = .587).
Conclusions
LV dysfunction is common among potential heart donors. These hearts were safely transplanted in this study. The use of these hearts might significantly increase transplantation rates.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 10 Jul 2019; epub ahead of print
Oras J, Doueh R, Norberg E, Redfors B, Omerovic E, Dellgren G
J Thorac Cardiovasc Surg: 10 Jul 2019; epub ahead of print | PMID: 31427100
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Impact:
Abstract

Risk of reoperative valve surgery for endocarditis associated with drug use.

Mori M, Bin Mahmood SU, Schranz AJ, Sultan I, ... Gleason T, Geirsson A
Background
We aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting.
Methods
We formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS.
Results
The cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in ≥3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95% confidence interval, 1.22-4.06; P = .010).
Conclusions
An increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print
Mori M, Bin Mahmood SU, Schranz AJ, Sultan I, ... Gleason T, Geirsson A
J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print | PMID: 31420136
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Impact:
Abstract

Spatiotemporal imaging documented the maturation of the cardiomyocytes from human induced pluripotent stem cells.

Aoyama J, Homma K, Tanabe N, Usui S, ... Kaneda M, Nitta T
Objectives
Cardiomyocytes derived from human induced pluripotent stem cells are a promising source of cells for regenerative medicine. However, contractions in such derived cardiomyocytes are often irregular and asynchronous, especially at early stages of differentiation. This study aimed to determine the differentiation stage of initiation of synchronized and regular contractions, using spatiotemporal imaging and physiological and genetic analyses.
Methods
Knock-in human induced pluripotent stem cell lines were established with clustered regularly interspaced short palindromic repeats/clustered regularly interspaced short palindromic repeats-associated protein 9 to analyze cardiac and pacemaker cell maturation. Time-frequency analysis and Ca imaging were performed, and the expression of related proteins and specific cardiac/pacemaker mRNAs in contracting embryoid bodies was analyzed at various differentiation stages.
Results
Time-frequency analysis and Ca imaging revealed irregular, asynchronous contractions at the early stage of differentiation with altered electrophysiological properties upon differentiation. Genes associated with electrophysiological properties were upregulated after 70 days of culturing in differentiation media, whereas pacemaker genes were initially upregulated during the early stage and downregulated at the later stage.
Conclusions
A differentiation period >70 days is required for adequate development of cardiac elements including ion channels and gap junctions and for sarcomere maturation.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print
Aoyama J, Homma K, Tanabe N, Usui S, ... Kaneda M, Nitta T
J Thorac Cardiovasc Surg: 09 Jul 2019; epub ahead of print | PMID: 31409490
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Impact:
Abstract

Bicuspid valve aortopathy is associated with distinct patterns of matrix degradation.

Chim YH, Davies HA, Mason D, Nawaytou O, ... Madine J, Akhtar R
Objective
To explore the micromechanical, biochemical, and microstructural differences between bicuspid aortic valve aneurysm (BAV-A) and tricuspid aortic valve idiopathic degenerative aneurysm (DA), compared with normal aorta.
Methods
Aortic tissue was obtained from patients undergoing aneurysmal repair surgery (BAV-A; n = 15 and DA; n = 15). Control tissue was obtained from aortic punch biopsies during coronary artery bypass graft surgery (n = 9). Nanoindentation was used to determine the elastic modulus on the medial layer. Glycosaminoglycan, collagen, and elastin levels were measured using biochemical assays. Verhoeff Van Gieson-stained cross-sections were imaged for elastin microstructural quantification.
Results
The elastic modulus was more than 20% greater for BAV-A relative to control and DA (signifying a loss of compliance). No significance difference between control and DA were observed. Collagen levels for BAV-A (36.9 ± 7.4 μg/mg) and DA (49.9 ± 10.9 μg/mg) were greater compared with the control (30.2 ± 13.1 μg/mg). Glycosaminoglycan and elastin levels were not significant between the groups. Elastin segments were uniform throughout the control. Aneurysmal tissues had less elastin segments close to the intima and adventitia layers. Both BAV-A and DA had elastin segments compacted in the media; however, elastin segments were highly fragmented in DA.
Conclusions
BAV-A has a greater loss of aortic wall compliance relative to DA and the control. Although elastin levels were equal for all groups, spatial distribution of elastin provided a unique profile of matrix degradation for BAV-A. Elastin compaction within the media of BAV-A may have resulted from the altered hemodynamic pressure against the wall, which could explain for the stiffness of the tissue.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print
Chim YH, Davies HA, Mason D, Nawaytou O, ... Madine J, Akhtar R
J Thorac Cardiovasc Surg: 24 Sep 2019; epub ahead of print | PMID: 31679706
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Impact:
Abstract

Urotensin II, urotensin-related peptide, and their receptor in aortic valve stenosis.

Khan K, Albanese I, Yu B, Shalal Y, ... Cerutti M, Schwertani A
Objectives
Aortic valve stenosis (AVS) is the most common cause of surgical valve replacement worldwide. The vasoactive peptide urotensin II (UII) is upregulated in atherosclerosis and several other cardiovascular diseases; however, its role in the pathogenesis of AVS remains to be determined. Here, we investigated the expression of UII, urotensin-related peptide (URP), and the urotensin receptor (UT) and the role this system plays in AVS.
Methods
Immunohistochemistry and reverse-transcriptase polymerase chain reaction were used to examine the cellular localization and mRNA expression, of UII, URP, and UT in calcified and noncalcified aortic valves. Human aortic valve interstitial cells were isolated from normal valves and treated with UII or URP, and changes in cell proliferation, cholesterol efflux, calcium deposition, and β-catenin translocation were assessed.
Results
The mRNA expression of UII, URP, and UT was significantly greater in patients with AVS. There was abundant presence of UII, URP, and UT immunostaining in diseased compared with nondiseased valves and correlated significantly with presence of calcification (P < .0001) and fibrosis (P < .0001). Treating human aortic valve interstitial cells with UII or URP significantly increased cell proliferation (P < .0001) and decreased cholesterol efflux (P = .0011 and P = .0002, respectively). UII also significantly reduced ABCA1 protein expression (P = .0457) and increased β-catenin nuclear translocation (P < .0001) and mineral deposition (P < .0001).
Conclusions
Together, these data suggest that the urotensin system plays a role in the pathogenesis of AVS and warrants further investigation.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print
Khan K, Albanese I, Yu B, Shalal Y, ... Cerutti M, Schwertani A
J Thorac Cardiovasc Surg: 25 Sep 2019; epub ahead of print | PMID: 31679703
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Impact:
Abstract

Off-pump versus on-pump coronary artery bypass grafting in moderate renal failure.

Rocha RV, Yanagawa B, Hussain MA, Tu JV, ... Ouzounian M, Cusimano RJ
Objectives
Off-pump coronary artery bypass (OPCAB) may benefit select high-risk patients. We sought to analyze the long-term outcomes of OPCAB versus on-pump coronary artery bypass (ONCAB) in patients with moderate renal failure.
Methods
A retrospective cohort analysis of primary isolated CAB surgery performed in Ontario, Canada, from October 2008 to March 2016 in the CorHealth Ontario Cardiac Registry identified 50,115 cases. Of these, 7782 (15.5%) had estimated glomerular filtration rate (eGFR) of 30 to 59 mL/min/1.73 m. OPCAB was compared to ONCAB after propensity score matching.
Results
Following propensity score matching, 1578 patient pairs were formed. Total number of bypass grafts was higher in ONCAB (3.31 ± 1.01 vs 3.12 ± 1.14; P < .01) and more arterial grafts were used in OPCAB (1.55 ± 0.71 vs 1.14 ± 0.58; P < .01). OPCAB was associated with lower rate of in-hospital stroke (0.7% vs 2.2%; P < .01), renal failure requiring dialysis (1.2% vs 2.9%; P < .01), and blood transfusion (52.4% vs 69.3%; P < .01). There was no difference in perioperative mortality (2.4% vs 3.0%; P = .36) between OPCAB and ONCAB, respectively. At 8-year follow-up, survival probability was not different when comparing OPCAB versus ONCAB: 62% versus 65%, respectively (hazard ratio, 0.98; 95% confidence interval, 0.84-1.13; P = .38). Cumulative incidence of permanent dialysis did not differ at 8-year follow-up: 7% versus 7%, respectively (hazard ratio, 1.01; 95% confidence interval, 0.72-1.43; P = .74.
Conclusions
OPCAB is associated with improved in-hospital renal outcomes, but is not associated with changes in short- or long-term mortality, or with the long-term cumulative incidence of end-stage renal failure requiring permanent dialysis in patients with moderate renal failure.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 17 Jun 2019; epub ahead of print
Rocha RV, Yanagawa B, Hussain MA, Tu JV, ... Ouzounian M, Cusimano RJ
J Thorac Cardiovasc Surg: 17 Jun 2019; epub ahead of print | PMID: 31409492
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Impact:
Abstract

Propensity and impact of autologous platelet rich plasma use in acute type A dissection.

Sandhu HK, Tanaka A, Dahotre S, Charlton-Ouw KM, ... Safi HJ, Zhou SF
Background
Coagulopathy in patients undergoing open repair of acute type A aortic dissection using cardiopulmonary bypass and hypothermic circulatory arrest is a common complication. Autologous platelet rich plasma is an intraoperative blood conservation technique, which has been shown in previous studies to promote hemostasis, leading to a reduction of blood product transfusions during elective aortic surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet rich plasma as a blood conservation technique during open surgical repair of acute type A aortic dissection.
Methods
We reviewed all acute type A aortic dissection cases using hypothermic circulatory arrest, excluding patients presenting in extremis. Perioperative transfusion requirements and clinical outcomes were analyzed. The end points analyzed included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay. Parsimonious and saturated propensity scores were calculated for platelet rich plasma use, and all outcomes were propensity adjusted.
Results
Between 2003 and 2014, 85 of 391 acute type A aortic dissection repairs used autologous platelet rich plasma. Mean age of patients was 58 ± 15 years, and 70% were male. Obstructive sleep apnea (22% vs 13%, P = .04) and baseline ejection fraction (57% ± 6.7% vs 55% ± 10%; P = .014) were higher in the autologous platelet rich plasma group. Intraoperative propensity-adjusted blood products, 2 units fewer packed red blood cells (P = .001), 4 units fewer fresh-frozen plasma (P = .001), 6 units fewer platelets (P = .001), 1.3 units fewer cell-savers (P = .002), and 5 units fewer cryoprecipitate (P = .001) were significantly reduced by autologous platelet rich plasma use. Significant unadjusted reduction in postoperative reoperation for bleeding (8% vs 17%, P = .046) after autologous platelet rich plasma was reported, although propensity adjustment eliminated significance (P = .079). No difference in stroke, cardiac, or renal complications was observed. Postoperative transfusion needed during the first 3 days was significantly reduced in the autologous platelet rich plasma group: 2 units fewer packed red blood cells (P = .13), 2 units fewer fresh-frozen plasma (P = .018), and 5 units fewer platelets (P = .001), when compared with those without autologous platelet rich plasma. Ventilation time was reduced by 3 days (P = .002), and intensive care length of stay was reduced by 3 days (P = .063) after intraoperative autologous platelet rich plasma use.
Conclusions
The use of autologous platelet rich plasma in patients undergoing open repair of acute type A aortic dissection was associated with a reduction in intraoperative and postoperative blood transfusions, as well as decreased early postoperative morbidity.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 14 Jun 2019; epub ahead of print
Sandhu HK, Tanaka A, Dahotre S, Charlton-Ouw KM, ... Safi HJ, Zhou SF
J Thorac Cardiovasc Surg: 14 Jun 2019; epub ahead of print | PMID: 31519411
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Impact:
Abstract

Predialysis coronary revascularization and postdialysis mortality.

Gaipov A, Molnar MZ, Potukuchi PK, Sumida K, ... Kalantar-Zadeh K, Kovesdy CP
Objectives
Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with mild-to-moderate chronic kidney disease (CKD) and End-Stage Renal Disease (ESRD). However, the optimal strategy for coronary artery revascularization in advanced CKD patients who transition to ESRD is unclear.
Methods
We examined a contemporary national cohort of 971 US veterans with incident ESRD, who underwent first CABG or PCI up to 5 years prior to dialysis initiation. We examined the association of a history of CABG versus PCI with all-cause mortality following transition to dialysis, using Cox proportional hazards models adjusted for time between procedure and dialysis initiation, socio-demographics, comorbidities and medications.
Results
582 patients underwent CABG and 389 patients underwent PCI. The mean age was 66±8 years, 99% of patients were male, 79% were white, 19% were African Americans, and 84% were diabetics. The all-cause post-dialysis mortality rates after CABG and PCI were 229/1000 patient-years (PY) [95% CI: 205-256] and 311/1000PY [95% CI: 272-356], respectively. Compared to PCI, patients who underwent CABG had 34% lower risk of death [multivariable adjusted Hazard Ratio (95% CI) 0.66 (0.51-0.86), p=0.002] after initiation of dialysis. Results were similar in all subgroups of patients stratified by age, race, type of intervention, presence/absence of myocardial infarction, congestive heart failure and diabetes.
Conclusion
CABG in advanced CKD patients was associated lower risk of death after initiation of dialysis compared to PCI.



J Thorac Cardiovasc Surg: 27 Feb 2019; 157:976-983.e7
Gaipov A, Molnar MZ, Potukuchi PK, Sumida K, ... Kalantar-Zadeh K, Kovesdy CP
J Thorac Cardiovasc Surg: 27 Feb 2019; 157:976-983.e7 | PMID: 31431793
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Impact:
Abstract

Intraoperative transit-time flow measurement and high-frequency ultrasound assessment in coronary artery bypass grafting.

Taggart DP, Thuijs DJFM, Di Giammarco G, Puskas JD, ... Kappetein AP, Head SJ
Objectives
We evaluated the influence of transit-time flow measurement with epicardial and epiaortic high-frequency ultrasound in patients undergoing coronary artery bypass grafting procedure.
Methods
The Registry for Quality Assessment with Ultrasound Imaging and Transit-time Flow Measurement in Cardiac Bypass Surgery study is a multicenter, prospective study among 7 international centers performing coronary artery bypass grafting procedures. The primary end point was any change in the planned surgical procedure. Major secondary end points consisted of the rate and reason for surgical changes related to the aorta, in situ conduits, coronary targets, and completed grafts, and the rate of in-hospital mortality and major morbidity.
Results
Between April 2015 and December 2017, 1046 patients were enrolled. Of those, 1016 were included in the final analyses. Mean age was 65.9 years, 14.0% were women, and diabetes was present in 39.6%. Off-pump procedures were performed in 39.6% and bilateral internal thoracic arteries in 30.5%. The primary end point occurred in 25.2% of patients (n = 256) and in 77% (197 out of 256) this was based on transit-time flow measurement and/or high-frequency ultrasound. Surgical changes were related to the aorta in 9.9%, to in situ conduits in 2.7%, and the coronary targets in 22.4%. Graft revision occurred in 7.8%, including revisions of the proximal and/or distal anastomosis in 6.6%. In-hospital adverse event rates were 0.6% for mortality, 1.0% for cerebrovascular events, and 0.3% for myocardial infarction.
Conclusions
Surgical changes related to the aorta, conduits, coronary targets, and anastomosis were made in 25% of patients. This was associated with low operative mortality and low major morbidity. Transit-time flow measurement and high-frequency ultrasound may improve the quality, safety, and efficacy of coronary artery bypass grafting procedures and should be considered as a routine procedural aspect.

Copyright © 2019 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print
Taggart DP, Thuijs DJFM, Di Giammarco G, Puskas JD, ... Kappetein AP, Head SJ
J Thorac Cardiovasc Surg: 21 Aug 2019; epub ahead of print | PMID: 31685277
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Impact:
Abstract

Outcomes of major complications after robotic anatomic pulmonary resection.

Cao C, Louie BE, Melfi F, Veronesi G, ... Ranganath NK, Park BJ
Background
There is a paucity of robust clinical data on major postoperative complications following robotic-assisted resection for primary lung cancer. This study assessed the incidence and outcomes of patients who experienced major complications after robotic anatomic pulmonary resection.
Methods
This was a multicenter, retrospective review of patients who underwent robotic anatomic pulmonary resection between 2002 and 2018. Major complications were defined as grade III or higher complications according to the Clavien-Dindo classification. Statistical analysis was performed based on patient-, surgeon-, and treatment-related factors.
Results
During the study period, 1264 patients underwent robotic anatomic pulmonary resections, and 64 major complications occurred in 54 patients (4.3%). Univariate analysis identified male sex, forced expiratory volume in 1 second, diffusion capacity of the lung for carbon monoxide, neoadjuvant therapy, and extent of resection as associated with increased likelihood of a major postoperative complication. Patient age, performance status, body mass index, reoperation status, and surgeon experience did not have a significant impact on major complications. Patients who experienced at least 1 major complication were at higher risk for an intensive care unit stay of >24 hours (17.0% vs 1.4%; P < .001) and prolonged hospitalization (8.5 days vs 4 days; P < .001). Patients who experienced a major postoperative complication had a 14.8% risk of postoperative death.
Conclusions
In this series, the major complication rate during the postoperative period was 4.3%. A number of identified patient- and treatment-related factors were associated with an increased risk of major complications. Major complications had a significant impact on mortality and duration of stay.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 17 Sep 2019; epub ahead of print
Cao C, Louie BE, Melfi F, Veronesi G, ... Ranganath NK, Park BJ
J Thorac Cardiovasc Surg: 17 Sep 2019; epub ahead of print | PMID: 31685275
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Impact:
Abstract

Reducing delirium and cognitive dysfunction after off-pump coronary bypass: A randomized trial.

Szwed K, Pawliszak W, Szwed M, Tomaszewska M, Anisimowicz L, Borkowska A
Background
Neuropsychiatric complications of surgical coronary revascularization are inconspicuous but frequent and clinically relevant. So far, attempts to reduce their occurrence, such as the introduction of off-pump coronary artery bypass (OPCAB) grafting method, have not brought the desired results. The aim of this trial was to determine whether using any of the 2 selected modifications of OPCAB could decrease the incidence of these undesired sequelae.
Methods
In this single-center, assessor- and patient-blinded, superiority, randomized controlled trial, 192 patients scheduled for elective isolated OPCAB were randomized to 3 parallel arms. The control arm underwent \"conventional\" OPCAB with vein grafts. The first study arm underwent anaortic OPCAB (ANA) with total arterial revascularization. The second study arm underwent OPCAB with vein grafts using carbon dioxide surgical field flooding (COFF). Outcomes included the incidence of postoperative delirium (PD) and early postoperative cognitive dysfunction (ePOCD).
Results
The incidence of PD was 35.9% in the control (OPCAB) arm, 32.8% in the COFF arm, and 12.5% in the ANA arm (χ [2, N = 191] = 10.17; P = .006). Post hoc tests revealed that the incidence of PD in the ANA arm differed from that in the OPCAB arm (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09-0.68; P = .002). The incidence of ePOCD was 34.4% in the OPCAB arm, 28.1% in the COFF arm, and 9.5% in the ANA arm (χ [2, N = 191] = 11.58; P = .003). Post hoc tests revealed that the incidence of ePOCD differed between the ANA and OPCAB arms (OR, 0.20; 95% CI, 0.06-0.58; P < .001).
Conclusions
Performing ANA significantly decreases the incidence of PD and ePOCD compared with \"conventional\" OPCAB with vein grafts, whereas COFF is inconsequential in this regard. These results, which probably reflect decreased delivery of embolic load to the brain in ANA, may have practical applicability in daily practice to improve clinical outcomes.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 30 Sep 2019; epub ahead of print
Szwed K, Pawliszak W, Szwed M, Tomaszewska M, Anisimowicz L, Borkowska A
J Thorac Cardiovasc Surg: 30 Sep 2019; epub ahead of print | PMID: 31685272
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Abstract

Influence of pregnancy on long-term durability of allografts in right ventricular outflow tract.

Romeo JLR, Papageorgiou G, Takkenberg JJM, Roos-Hesselink JW, ... Bogers AJJC, Mokhles MM
Background
There is very limited published evidence about the influence of pregnancy on allograft durability in right ventricular outflow tract position. We present the first study using mixed and joint modeling.
Methods
This retrospective study compared clinical and valve related outcomes of all consecutive female hospital survivors in their fertile life phase (18-50 years) based on pregnancy. Serial echocardiographic measurements of pulmonary gradient and regurgitation were analyzed for their association with valve replacement using joint models for longitudinal and time-to-event data. Occurrence of first pregnancy was included as a time-dependent intermediate event in both the longitudinal and survival analyses of the joint model to assess its impact on the hemodynamic and clinical outcome.
Results
In total, 196 consecutive women in their fertile life-phase with an allograft were included. Complete information of 176 (90%) allografts in 165 women was available, including 1395 echocardiograms. Of these women, 51 (30.9%) women had 84 completed pregnancies at an average age of 29.1 ± 3.9 (SD) years; 8.1 ± 6.1 years since allograft implantation. Tetralogy of Fallot was the most common diagnosis in both groups. After a mean follow-up of 15.2 years (range 0.1-30), 7 (13.7%) parous women underwent valve replacement versus 20 (17.5%) nulliparous women. During this follow-up, the mean allograft gradient in parous (24.2 mm Hg) and nulliparous (21.0 mm Hg) women was comparable (P = .225). A 1-mm Hg increase in pulmonary gradient increased the instantaneous risk of pulmonary valve replacement (PVR) by a ratio of 1.051 (P < .001), regardless of pregnancy. Similarly, development of moderate or severe regurgitation increased the risk of PVR (P = .038), regardless of pregnancy. Pregnancy was not associated with a change in the allograft gradient (P = .258), regurgitation grade (P = .774), or hazard of PVR (P = .796) during follow-up.
Conclusions
Pregnancy is not associated with impaired allograft durability in women with good cardiac health.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 03 Oct 2019; epub ahead of print
Romeo JLR, Papageorgiou G, Takkenberg JJM, Roos-Hesselink JW, ... Bogers AJJC, Mokhles MM
J Thorac Cardiovasc Surg: 03 Oct 2019; epub ahead of print | PMID: 31706555
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Abstract

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs.

Tanaka A, Sandhu HK, Afifi RO, Miller CC, ... Safi HJ, Estrera AL
Objective
To review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR).
Methods
Between February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods.
Results
Thirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m, previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004).
Conclusions
Open surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 30 Sep 2019; epub ahead of print
Tanaka A, Sandhu HK, Afifi RO, Miller CC, ... Safi HJ, Estrera AL
J Thorac Cardiovasc Surg: 30 Sep 2019; epub ahead of print | PMID: 31699416
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Abstract

Non-vitamin K oral anticoagulant use after cardiac surgery is rapidly increasing.

Beller JP, Krebs ED, Hawkins RB, Mehaffey JH, ... Teman NR, Ailawadi G
Objective
The prevalence of non-vitamin K oral anticoagulant use after cardiac surgery is unknown, particularly in patients with bioprosthetic valves. We sought to define the contemporary use and short-term safety of non-vitamin K oral anticoagulants after cardiac surgery.
Methods
All patients undergoing bioprosthetic aortic valve replacement, bioprosthetic mitral valve replacement, or isolated coronary artery bypass grafting (2011-2018) were evaluated from a multicenter, regional Society of Thoracic Surgeons database. Patients were stratified by anticoagulant type (non-vitamin K oral anticoagulant vs vitamin K antagonist) and era (early [2011-2014] vs contemporary [2015-2018]).
Results
Of 34,188 patients, 18% (6063) were discharged on anticoagulation, of whom 23% were prescribed non-vitamin K oral anticoagulants. Among those receiving anticoagulation, non-vitamin K oral anticoagulant use has significantly increased from 10.3% to 35.4% in contemporary practice (P < .01). This trend was observed for each operation type (coronary artery bypass grafting 0.86%/year, bioprosthetic aortic valve replacement: 2.15%/year, bioprosthetic mitral valve replacement: 2.72%/year, all P < .01). In patients with postoperative atrial fibrillation receiving anticoagulation, non-vitamin K oral anticoagulant use has increased from 6.3% to 35.4% and 12.3% to 40.3% after bioprosthetic valve replacement and isolated coronary artery bypass grafting, respectively (both P < .01). In patients receiving anticoagulation at discharge, adjusted 30-day mortality (odds ratio, 1.94; P = .12) and reoperation (odds ratio, 0.79; P = .34) rates were not associated with anticoagulant choice, whereas non-vitamin K oral anticoagulant use was associated with an adjusted 0.9-day decrease (P < .01) in postoperative length of stay.
Conclusions
Non-vitamin K oral anticoagulant use after cardiac surgery has dramatically increased since 2011. This trend is consistent regardless of indication for anticoagulation including bioprosthetic valves. Short-term outcomes support their safety in the cardiac surgery setting with shorter postoperative hospital stays. Long-term studies on the efficacy of non-vitamin K oral anticoagulants after cardiac surgery are still necessary.

Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Sep 2019; epub ahead of print
Beller JP, Krebs ED, Hawkins RB, Mehaffey JH, ... Teman NR, Ailawadi G
J Thorac Cardiovasc Surg: 27 Sep 2019; epub ahead of print | PMID: 31706560
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Abstract

The influence of adjuvant therapy on survival in patients with indeterminate margins following surgery for non-small cell lung cancer.

Raman V, Jawitz OK, Yang CJ, Voigt SL, ... D\'Amico TA, Harpole DH
Background
The significance of indeterminate margins following surgery for non-small cell lung cancer (NSCLC) is unknown. We evaluated the influence of adjuvant therapy on survival in patients whose cancer showed indeterminate margins.
Methods
Patients whose cancer showed indeterminate margins following surgery for NSCLC were identified in the National Cancer Database between 2004 and 2015, and stratified by receipt of adjuvant treatment. The primary outcome was overall survival, which was evaluated with multivariable Cox proportional hazards.
Results
Indeterminate margins occurred in 0.31% of 232,986 patients undergoing surgery for NSCLC and was associated with worse survival compared with margin negative resection (adjusted hazard ratio, 1.53; 95% confidence interval, 1.40-1.67). Anatomic resection was protective against the finding of indeterminate margins in logistic regression. Amongst 553 patients with indeterminate margins, 343 (62%) received no adjuvant therapy, 96 (17%) received adjuvant chemotherapy, 33 (6%) received adjuvant radiation, and 81 (15%) received adjuvant chemoradiation. Any mode of adjuvant therapy was not associated with improved survival compared with no further treatment.
Conclusions
The finding of indeterminate margins is reported in 0.31% of patients undergoing curative-intent surgery for NSCLC. This was associated with worse overall survival compared with complete resection and not mitigated by adjuvant therapy. The risks and benefits of adjuvant therapy should be carefully considered for patients with indeterminate margins after surgery for NSCLC.

Copyright © 2019. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print
Raman V, Jawitz OK, Yang CJ, Voigt SL, ... D'Amico TA, Harpole DH
J Thorac Cardiovasc Surg: 29 Sep 2019; epub ahead of print | PMID: 31706554
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This program is still in alpha version.