Journal: J Thorac Cardiovasc Surg

Sorted by: date / impact
Abstract

Our experience with 1000 recent thoracoabdominal aneurysm repairs, including endovascular stenting.

Svensson LG
Objective
Managing patients with thoracoabdominal aneurysms is demanding yet fascinating, and requires a team effort. This invited talk presents lessons learned as our history with open and endovascular procedures evolved for 2578 descending and thoracoabdominal repairs over the past 20 years.
Methods
Beginning in 1985 with an analysis of 596 traumatic aortic ruptures and the risk of spinal cord ischemia, the evolution of research and procedures for thoracoabdominal aneurysms progressed. The focus of these studies, medication trials, and procedure adjustments was on lowering the risk of spinal cord ischemia.
Results
Between January 2002 and December 2021, 2578 aneurysm repairs were performed. The respective mortality rates were 6.8% and 4.0% for all patients treated. The permanent spinal cord ischemia rates were 1.3% for open descending thoracic aortas and 4.9% for open thoracoabdominal aneurysms. A detailed analysis of open and thoracoabdominal repairs showed better long-term outcomes with open repairs.
Conclusions
Through multiple randomized trials and innovations with procedures and techniques, the risk of death and spinal cord ischemia have been reduced. Long-term survival has also been improved. The pursuit of reducing the risks of descending and ascending thoracoabdominal repairs is a fascinating endeavor that has resulted in better patient outcomes. Nevertheless, this is a journey, and there will always be more room to achieve even better results.

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

J Thorac Cardiovasc Surg: 09 May 2022; epub ahead of print
Svensson LG
J Thorac Cardiovasc Surg: 09 May 2022; epub ahead of print | PMID: 35589422
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial.

Gaudino M, Castelvecchio S, Rahouma M, Robinson NB, ... Velazquez EJ, Menicanti L
Objective
The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH) trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH trial using individual patient data.
Methods
Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality.
Results
The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001).
Conclusions
Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH trial, suggesting that a new trial testing the SVR hypothesis may be warranted.

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

J Thorac Cardiovasc Surg: 26 Apr 2022; epub ahead of print
Gaudino M, Castelvecchio S, Rahouma M, Robinson NB, ... Velazquez EJ, Menicanti L
J Thorac Cardiovasc Surg: 26 Apr 2022; epub ahead of print | PMID: 35599207
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Ross procedure in neonates and infants: A valuable operation with defined limits.

Cleveland JD, Bansal N, Wells WJ, Wiggins LM, Kumar SR, Starnes VA
Objective
The Ross procedure is an important tool that offers autologous tissue repair for severe left ventricular outflow tract (LVOT) pathology. Previous reports show that risk of mortality is highest among neonates and infants. We analyzed our institutional experience within this patient cohort to identify factors that most affect clinical outcome.
Methods
A retrospective chart review identified all Ross operations in neonates and infants at our institution over 27 years. The entire study population was analyzed to determine risk factors for mortality and define outcomes for survival and reintervention.
Results
Fifty-eight patients underwent a Ross operation at a median age of 63 (range, 9-156) days. Eighteen (31%) were neonates. Eleven (19%) patients died before hospital discharge. Multiple regression analysis of the entire cohort identified young age (hazard ratio [HR], 1.037; P = .0045), Shone complex (HR, 17.637; P = .009), and interrupted aortic arch with ventricular septal defect (HR, 16.01; P = .031) as independent predictors of in-hospital mortality. Receiver operating characteristic analysis (area under the curve, 0.752) indicated age younger than 84 days to be the inflection point at which mortality risk increases. Of the 47 survivors, there were 2 late deaths with a mean follow-up of 6.7 (range, 2.1-13.1) years. Three patients (6%) required LVOT reintervention at 3, 8, and 17.5 years, respectively, and 26 (55%) underwent right ventricular outflow tract reintervention at a median of 6 (range, 2.5-10.3) years.
Conclusions
Ross procedure is effective in children less than one year of age with left sided obstructive disease isolated to the aortic valve and/or aortic arch. Patients less than 3 months of age with Shone or IAA/VSD are at higher risk for morbidity and mortality. Survivors experience excellent intermediate-term freedom from LVOT reintervention.

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

J Thorac Cardiovasc Surg: 25 Apr 2022; epub ahead of print
Cleveland JD, Bansal N, Wells WJ, Wiggins LM, Kumar SR, Starnes VA
J Thorac Cardiovasc Surg: 25 Apr 2022; epub ahead of print | PMID: 35599209
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Aortic arch isolation to reduce cerebral embolic risk during replacement of the atherosclerotic aortic arch.

Park SJ, Kim HR, Shinn SH, Kim HJ, Jung SH, Choo SJ
Objective
To analyze the efficacy of isolating the upper body circulation from the lower body (isolation technique) in reducing the risk of embolic stroke during cardiopulmonary bypass in patients with severe atherosclerosis undergoing aortic arch surgery.
Methods
Between 2006 and 2019, 156 patients with severe atherosclerosis undergoing total arch replacement were enrolled. Since 2017, the right axillary or innominate artery and ascending aorta were both cannulated before cardiopulmonary bypass in the isolation group (n = 30). The left common carotid artery was clamped and inserted with a 13-Fr balloon perfusion catheter. The innominate artery was clamped in succession and cardiopulmonary bypass was instituted, establishing a parallel noncommunicating circulation for the upper and lower body. Patients without atherosclerosis that were not considered at high risk of embolic complications were excluded. The no-isolation group was drawn from historically matched control patients undergoing total arch replacement.
Results
The permanent stroke rate in the isolation and no-isolation groups were 3.3% (n = 1) and 15.9% (n = 15.9), respectively. After inverse-probability-of-treatment-weighting adjustment, the early mortality (P = .043), stroke (P = .044), and composite of early mortality or stroke (P = .005) rates were significantly lower in the isolation group. The logistic regression analysis after inverse-probability-of-treatment-weighting risk adjustment showed a significantly reduced composite risk of early death and stroke in the isolation group (odds ratio, 0.09; 95% confidence interval, 0.01-0.70; P = .023).
Conclusions
The isolation technique was associated with a significant reduction in early postoperative embolic stroke and mortality risks in patients with severe aortic atherosclerosis undergoing total arch replacement.

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

J Thorac Cardiovasc Surg: 25 Apr 2022; epub ahead of print
Park SJ, Kim HR, Shinn SH, Kim HJ, Jung SH, Choo SJ
J Thorac Cardiovasc Surg: 25 Apr 2022; epub ahead of print | PMID: 35606177
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Contemporary socioeconomic-based disparities in cardiac surgery: Are we closing the disparities gap?

Newell P, Asokan S, Zogg C, Prasanna A, ... Kerolos M, Kaneko T
Objective
Female sex and lower income residence location are associated with worse health care outcomes. In this study we analyzed the national, contemporary status of socioeconomic disparities in cardiac surgery.
Methods
Adult patients within the Nationwide Readmissions Database who underwent coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), mitral valve (MV) replacement, MV repair, or ascending aorta surgery from 2016 to 2018 were included. Sex and median household income quartile (MHIQ) were compared within each surgery group. Primary outcome was 30-day mortality. Multivariable analysis was adjusted for patient characteristics and hospital-level factors.
Results
A weighted total of 358,762 patients were included. Fewer women underwent CABG (22.3%), SAVR (32.2%), MV repair (37.5%), and ascending aorta surgery (29.7%). In adjusted analysis, female sex was independently associated with higher 30-day mortality rates after CABG (adjusted odds ratio [aOR], 1.6), SAVR (aOR, 1.4), MV repair (aOR, 1.8), and ascending aorta surgery (aOR, 1.2; all P < .03). The lowest MHIQ was independently associated with higher 30-day mortality rates after CABG (aOR, 1.4), SAVR (aOR, 1.5), MV replacement (aOR, 1.3), and ascending aorta surgery (aOR, 1.8; all P < .004) compared with the highest quartile. Women were less likely to receive care at urban and academic hospitals for CABG compared with men. Patients of lower MHIQ received less care at urban and academic institutions for all surgeries.
Conclusions
Despite advances in the techniques and safety, women and patients of lower socioeconomic status continue to have worse outcomes after cardiac surgery. These persistent disparities warrant the need for root cause analysis.

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

J Thorac Cardiovasc Surg: 22 Apr 2022; epub ahead of print
Newell P, Asokan S, Zogg C, Prasanna A, ... Kerolos M, Kaneko T
J Thorac Cardiovasc Surg: 22 Apr 2022; epub ahead of print | PMID: 35570024
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Early ligation of the pulmonary vein can reduce the dissemination of shed tumor cells during thoracoscopic lobectomy.

Duan X, Yang Z, Hao X, Zhou S, ... Zhang K, Cui Y
Objective
The sequence of vessel ligation in lobectomy can significantly affect the hematogenous spread of circulating tumor cells (CTCs). Vein-first ligation substantially reduces CTC dissemination and achieves favorable survival compared with artery-first ligation. In this study, we further explored whether the timing of pulmonary vein (PV) ligation determined according to the early and late PV ligation technique is associated with CTC dissemination.
Methods
A total of 44 patients who underwent uniform 2-port video-assisted thoracoscopic surgery lobectomy were enrolled; the subjects were divided into the early ligation group (n = 18) and late ligation group (n = 26) according to whether PV ligation was prioritized during surgery. PV blood was obtained before PV ligation and after lobe resection. CTCs were detected using telomerase reverse transcriptase-based CTC detection and validated using FlowSight and fluorescence in situ hybridization.
Results
The median postoperative PV CTC (Post-PVCTC) count was 9 (interquartile range [IQR], 6-18), which was higher than the median preoperative PV CTC (Pre-PVCTC) count of 1 (IQR, 0-3; P < .001). Clinicopathologic correlation analysis showed that the Pre-PVCTC count correlated positively with TNM stage (P = .002) and lymph node metastasis (P = .002) and that the Post-PVCTC count correlated positively with tumor density (P = .043) and vessel/lymphatic invasion (P < .030). Interestingly, although no statistical difference in the median Pre-PVCTC count was observed, the median Post-PVCTC count in the early ligation group was 16 (IQR, 9.5-36.75), whereas that in the late ligation group it was 8 (IQR, 4.75-12.25), showing a significant difference (P = .004).
Conclusions
We provide the first evidence to show that early PV ligation can prevent PVCTCs from spreading into the circulation, offering an innovative surgical concept for the principle sequence of pulmonary vessel management.

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

J Thorac Cardiovasc Surg: 20 Apr 2022; epub ahead of print
Duan X, Yang Z, Hao X, Zhou S, ... Zhang K, Cui Y
J Thorac Cardiovasc Surg: 20 Apr 2022; epub ahead of print | PMID: 35589423
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Improvement in gastrointestinal bleeding after septal myectomy for hypertrophic cardiomyopathy.

Sun D, Schaff HV, Lentz Carvalho J, Nishimura RA, ... Blackshear JL, Geske JB
Objective
Patients with obstructive hypertrophic cardiomyopathy may have occult gastrointestinal bleeding. In this study, we analyzed outcomes of septal myectomy in patients who had a history of gastrointestinal bleeding preoperatively to understand patient characteristics and impact of septal reduction on recurrent gastrointestinal bleeding.
Methods
We analyzed 73 adult patients who had a history of gastrointestinal bleeding before transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and compared outcomes to 219 patients without gastrointestinal bleeding preoperatively.
Results
Patients with preoperative history of gastrointestinal bleeding were older (median (IQR) age, 65 (59-69) years, P < .001) and were more likely to have systemic hypertension (70% vs 53%, P = .020) and coronary artery disease (25% vs 13%, P = .026). Preoperatively, patients with gastrointestinal bleeding had a larger left atrial volume index (median, 53 mL/m2; interquartile range, 42-67; P = .006) and greater right ventricular systolic pressure (median, 36 mm Hg; interquartile range, 32-49; mm Hg, P = .005) but no significant difference in severity of outflow tract obstruction (P = .368). There were no perioperative deaths. The estimated 5- and 10-year survivals were 96.6% and 81.8%, respectively. At a median of 3.4 (interquartile range, 1.9-9.1) years after septal myectomy, 11 patients (15%) had recurrence of gastrointestinal bleeding, which was attributed to angiodysplasia or unknown causes in 6 patients (8%).
Conclusions
Patients with a preoperative history of gastrointestinal bleeding have favorable short- and long-term outcomes after septal myectomy for obstructive hypertrophic cardiomyopathy. Remission of gastrointestinal bleeding was observed in 85% of patients postprocedure, and only 8% of the patients had recurrent gastrointestinal bleeding due to angiodysplasia or unknown causes.

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

J Thorac Cardiovasc Surg: 20 Apr 2022; epub ahead of print
Sun D, Schaff HV, Lentz Carvalho J, Nishimura RA, ... Blackshear JL, Geske JB
J Thorac Cardiovasc Surg: 20 Apr 2022; epub ahead of print | PMID: 35577596
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiac-type total anomalous pulmonary venous return is not benign.

Shi G, Zhu F, Wen C, Yan Y, ... Zhu Z, Chen H
Objective
The objective of this study was to investigate the association between morphological variation and postsurgical pulmonary vein (PV) stenosis (PPVS) in patients with cardiac total anomalous pulmonary venous connection (TAPVC).
Methods
This single-center, retrospective study included 168 pediatric patients who underwent surgical repair of cardiac TAPVC from 2013 to 2019 (connection to the coronary sinus [CS], n = 136; connection directly to the right atrium [RA], n = 32). Three-dimensional computed tomography modeling and geometric analysis were performed to investigate the morphological features; their relevance to the PPVS was examined.
Results
The connection type had no association with PPVS (CS type: 18% vs right atrial type: 19%; P = .89) but there was a higher incidence of PPVS in patients with a single PV orifice than > 1 orifice (P < .001). Confluence-to-total PV area ratio (hazard ratio, 4.78, 95% CI, 1.86-12.32; P = .001) and length of drainage route (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < .001) had a 4- and 1-fold increase in the risk for PPVS in the CS type after adjustment for age and preoperative pulmonary venous obstruction. In the right atrial type, those with anomalous PV return to the RA roof were more likely to develop PPVS than to the posterior wall of the RA (P < .001).
Conclusions
The number of inter-junction PV orifice correlated with PPVS development in cardiac TAPVC. The confluence-to-total PV ratio, length of drainage route, and anomalous PV return to the RA roof are important predictors for PPVS. Morphological subcategorization in this clinical setting can potentially assist in surgical decision-making.

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

J Thorac Cardiovasc Surg: 19 Apr 2022; epub ahead of print
Shi G, Zhu F, Wen C, Yan Y, ... Zhu Z, Chen H
J Thorac Cardiovasc Surg: 19 Apr 2022; epub ahead of print | PMID: 35570017
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Steen solution protects pulmonary microvascular endothelial cells and preserves endothelial barrier after lipopolysaccharide-induced injury.

Ta HQ, Teman NR, Kron IL, Roeser ME, Laubach VE
Objectives
Acute respiratory distress syndrome represents the devastating result of acute lung injury, with high mortality. Limited methods are available for rehabilitation of lungs affected by acute respiratory distress syndrome. Our laboratory has demonstrated rehabilitation of sepsis-injured lungs via normothermic ex vivo and in vivo perfusion with Steen solution (Steen). However, mechanisms responsible for the protective effects of Steen remain unclear. This study tests the hypothesis that Steen directly attenuates pulmonary endothelial barrier dysfunction and inflammation induced by lipopolysaccharide.
Methods
Primary pulmonary microvascular endothelial cells were exposed to lipopolysaccharide for 4 hours and then recovered for 8 hours in complete media (Media), Steen, or Steen followed by complete media (Steen/Media). Oxidative stress, chemokines, permeability, interendothelial junction proteins, and toll-like receptor 4-mediated pathways were assessed in pulmonary microvascular endothelial cells using standard methods.
Results
Lipopolysaccharide treatment of pulmonary microvascular endothelial cells and recovery in Media significantly induced reactive oxygen species, lipid peroxidation, expression of chemokines (eg, chemokine [C-X-C motif] ligand 1 and C-C motif chemokine ligand 2) and cell adhesion molecules (P-selectin, E-selectin, and vascular cell adhesion molecule 1), permeability, neutrophil transmigration, p38 mitogen-activated protein kinase and nuclear factor kappa B signaling, and decreased expression of tight and adherens junction proteins (zonula occludens-1, zonula occludens-2, and vascular endothelial-cadherin). All of these inflammatory pathways were significantly attenuated after recovery of pulmonary microvascular endothelial cells in Steen or Steen/Media.
Conclusions
Steen solution preserves pulmonary endothelial barrier function after lipopolysaccharide exposure by promoting an anti-inflammatory environment via attenuation of oxidative stress, toll-like receptor 4-mediated signaling, and conservation of interendothelial junctions. These protective mechanisms offer insight into the advancement of methods for in vivo lung perfusion with Steen for the treatment of severe acute respiratory distress syndrome.

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

J Thorac Cardiovasc Surg: 18 Apr 2022; epub ahead of print
Ta HQ, Teman NR, Kron IL, Roeser ME, Laubach VE
J Thorac Cardiovasc Surg: 18 Apr 2022; epub ahead of print | PMID: 35577593
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Incidence, characteristics, and outcomes of reintervention after mitral transcatheter edge-to-edge repair.

Kaneko T, Newell PC, Nisivaco S, Yoo SGK, ... Ailawadi G, Thompson M
Objective
The use of transcatheter edge-to-edge repair (TEER) is growing substantially, and reintervention after TEER by way of repeat TEER or mitral valve surgery (MVS) is increasing as a result. In this nationally representative study we examined the incidence, characteristics, and outcomes of reintervention after index TEER.
Methods
Between July 2013 and November 2017, we reviewed 11,396 patients who underwent index TEER using Medicare beneficiary data. These patients were prospectively tracked and identified as having repeat TEER or MVS. Primary outcomes included 30-day mortality, 30-day readmission, 30-day composite morbidity, and cumulative survival.
Results
Among 11,396 patients who underwent TEER, 548 patients (4.8%) required reintervention after a median time interval of 4.5 months. Overall 30-day mortality was 8.6%, 30-day readmission was 20.9%, and 30-day composite morbidity was 48.2%. According to reintervention type, 294 (53.7%) patients underwent repeat TEER, and 254 (46.3%) underwent MVS. Patients who underwent MVS were more likely to be younger and female, but had a similar comorbidity burden compared with the repeat TEER cohort. After adjustment, there were no differences in 30-day mortality (adjusted odds ratio [AOR], 1.26 [95% CI, 0.65-2.45]) or 30-day readmission (AOR, 1.14 [95% CI, 0.72-1.81]). MVS was associated with higher 30-day morbidity (AOR, 4.76 [95% CI, 3.17-7.14]) compared with repeat TEER. Requirement for reintervention was an independent risk factor for long-term mortality in a Cox proportional hazard model (hazard ratio, 3.26 [95% CI, 2.53-4.20]).
Conclusions
Reintervention after index TEER is a high-risk procedure that carries a significant mortality burden. This highlights the importance of ensuring procedural success for index TEER to avoid the morbidity of reintervention altogether.

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

J Thorac Cardiovasc Surg: 13 Apr 2022; epub ahead of print
Kaneko T, Newell PC, Nisivaco S, Yoo SGK, ... Ailawadi G, Thompson M
J Thorac Cardiovasc Surg: 13 Apr 2022; epub ahead of print | PMID: 35570022
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Surgical outcomes of infective endocarditis in pediatrics: Moving the needle to a contemporary, multidisciplinary approach.

Carrillo SA, Duenas H, Blaney C, Eisner M, Nandi D, McConnell PI
Background
Infective endocarditis (IE) is an uncommon disease in children that, when present, is accompanied by significant morbidity and mortality. The presence of congenital heart disease often complicates management. The aim of the present study is to describe the characteristics and outcomes of children undergoing surgery for IE.
Methods
A retrospective chart review from 2004 to 2020 was conducted to identify consecutive patients younger than age 20 years with IE undergoing surgery.
Results
A total of 94 patients with IE were identified, of whom 47 underwent surgery at a median age of 16.7 years. Thirty-one patients (65.95%) had congenital heart disease. Vegetation and embolic phenomena occurred in 41 and 29 patients (87.23% and 61.7%), respectively, with the brain as most common location (57.1%). Native valve involvement had a greater tendency to embolize (P < .001). Staphylococcus spp was the most common organism (49%). The mitral valve was the most affected (31.9%). Seven (14.9%) patients had multivalvar involvement and valve replacement was the most common procedure performed (37 patients; 78.7%). There were 3 operative deaths (6.4%). Median length of hospital stay was 21 days. Risk factors for prolonged hospital stay were time to surgery in days (P < .001) and native valvar involvement (P = .05). Five patients (10.6%) had postoperative recurrent IE. Survival at 1 and 5 years was 93.6% and 89.4%, respectively.
Conclusions
Children with IE can undergo surgery with acceptable results. The morbidity, but not mortality, is driven by embolic complications. Staphylococcus spp and native valve involvement are significant risk factors. VIDEO ABSTRACT.

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

J Thorac Cardiovasc Surg: 09 Apr 2022; epub ahead of print
Carrillo SA, Duenas H, Blaney C, Eisner M, Nandi D, McConnell PI
J Thorac Cardiovasc Surg: 09 Apr 2022; epub ahead of print | PMID: 35537892
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Differential expansion and outcomes of ascending and descending degenerative thoracic aortic aneurysms.

Huang Y, Schaff HV, Bagameri G, Pochettino A, ... Todd A, Greason KL
Objective
To evaluate expansion of degenerative thoracic aortic aneurysms (TAAs) and compare results between ascending and descending TAAs.
Methods
Among patients with diagnosis of degenerative TAA (1995-2015) in Olmsted County, we studied those having at least 2 computed tomography scans of TAA throughout the follow-up. Patients were classified as ascending or descending groups according to the segment where the maximal aortic diameter was measured. Primary end points were expansion rates and factors associated with TAA growth.
Results
We investigated 137 patients, 70 (51.1%) of whom were women; 78 (56.9%) were in the ascending and 59 (43.1%) were in the descending group. Median baseline maximal aortic diameter was 48.5 mm (interquartile range, 47.0-49.9 mm) for ascending and 42.4 mm (interquartile range, 40.0-45.4 mm) for descending group (P < .001). Median expansion rate was higher in the descending than the ascending group (2.0 mm/year [interquartile range, 0.9-3.2 mm/year] vs 0.2 mm/year [IQR, 0.1-0.6 mm/year]; P < .001). Aneurysm in the descending aorta and larger baseline maximal aortic diameter were independently associated with TAA expansion. Advanced age and chronic obstructive pulmonary disease but not aneurysm size or location were independently associated with overall mortality (P < .05). Aneurysm in the descending aorta was associated with aortic-related events (P < .05).
Conclusions
Degenerative TAAs under surveillance expand slowly. Descending TAA and larger baseline maximal aortic diameter were independently associated with more rapid TAA expansion, but these factors did not influence all-cause mortality.

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

J Thorac Cardiovasc Surg: 09 Apr 2022; epub ahead of print
Huang Y, Schaff HV, Bagameri G, Pochettino A, ... Todd A, Greason KL
J Thorac Cardiovasc Surg: 09 Apr 2022; epub ahead of print | PMID: 35577595
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Negative pressure wound therapy in patients with diabetes undergoing left internal thoracic artery harvest: A randomized control trial.

Jenkins S, Komber M, Mattam K, Briffa N
Background
Patients with diabetes undergoing CABG are at risk of wound infection. Incisional negative pressure wound therapy has been shown to be effective in decreasing incidence of infection in high-risk wounds. Near infrared spectroscopy (NIRS) can be used to assess wound oxygenation and low values can predict infection.
Objectives
To evaluate utility of NIRS to assess wound oxygenation, to assess effect of sternotomy, left internal thoracic artery harvest, and wound dressing type on wound edge oxygenation.
Methods
In this blinded randomized control trial, patients with diabetes undergoing isolated coronary artery bypass grafting with a left internal thoracic artery were randomized to receive either incisional negative pressure wound therapy dressing or a standard dressing. NIRS measurements were made on the left upper arm (control), and left and right parasternal regions on day -1 (preoperative), day 5, and week 6 after surgery. Results were analyzed using repeated measures parametric methods.
Results
Eighty patients with diabetes were recruited, 40 to the incisional negative pressure wound therapy group and 40 to the standard dressing group. Adjusted NIRS readings dropped significantly in all patients by day 5 and partially recovered by week 6. In both groups, there was no difference between readings on the left and right. At all time points and on both sides, there was no difference in readings between patients in the 2 groups.
Conclusions
NIRS can be used to assess oxygenation adjacent to a sternotomy wound. Adjusted tissue oxygen levels change with time after sternotomy and left internal thoracic artery harvest in patients with diabetes. Wound dressing type does not influence day 5 wound edge oxygenation.

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

J Thorac Cardiovasc Surg: 09 Apr 2022; epub ahead of print
Jenkins S, Komber M, Mattam K, Briffa N
J Thorac Cardiovasc Surg: 09 Apr 2022; epub ahead of print | PMID: 35550716
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Characteristics and prognostic significance of right heart remodeling and tricuspid regurgitation after pulmonary endarterectomy.

Hayashi H, Ning Y, Kurlansky P, Vaynrub A, ... Rosenzweig EB, Takeda K
Objective
Right heart remodeling and tricuspid regurgitation (TR) are common in patients with chronic thromboembolic pulmonary hypertension. This study aimed to investigate the significance of right heart remodeling and TR after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension.
Methods
Patients who underwent PEA with preoperative and postoperative transthoracic echocardiograms at our center between June 2010 and July 2019 were retrospectively reviewed. The composite end point was defined as death or hospitalization due to worsening heart failure, bleeding, or recurrent pulmonary embolism.
Results
In total, 158 patients were included for analysis. Right ventricular basal (48 [45-52] vs 43 [39-47] mm, P < .001), midcavitary (46 [42-50] vs 38 [34-42] mm, P < .001), and longitudinal dimensions (87 [83-93] vs 80 [75-84] mm, P < .001), along with the right atrial volume index (37 [25-51] vs 24 [18-34] mL/m2, P < .001), significantly decreased, whereas left ventricular and atrial sizes and left ventricular ejection fraction increased after PEA. Overall, 78 patients (49%) showed significant TR on preoperative transthoracic echocardiograms, and 33 (21%) had significant residual TR after PEA. Fourteen patients died, and 24 patients met the composite end point. Residual TR after PEA was independently associated with mortality (P = .005) and the composite end point (P = .003). Patients with residual TR had significantly worse survival (log-rank P < .001) and greater event rates (log-rank P = .003) than those without residual TR.
Conclusions
Significant improvements in right heart remodeling were seen following PEA. However, residual TR was a poor prognostic marker.

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

J Thorac Cardiovasc Surg: 08 Apr 2022; epub ahead of print
Hayashi H, Ning Y, Kurlansky P, Vaynrub A, ... Rosenzweig EB, Takeda K
J Thorac Cardiovasc Surg: 08 Apr 2022; epub ahead of print | PMID: 35534282
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Quantifying the effects of circulatory arrest on acute kidney injury in aortic surgery.

Hu D, Blitzer D, Zhao Y, Chan C, ... Patel V, Takayama H
Objectives
We aim to investigate the association between parameters surrounding circulatory arrest and postoperative acute kidney injury in aortic surgery.
Methods
This is a single-center retrospective study of 1118 adult patients who underwent aortic repair with median sternotomy between January 2010 and May 2019. Acute kidney injury was defined on the basis of a modified version of the 2012 Kidney Disease Improving Global Outcomes Scale that excluded urine output. The primary outcome of interest was any stage of acute kidney injury.
Results
Circulatory arrest was required in 369 patients, and 307 patients (27.5%) developed acute kidney injury: stage 1 in 241 patients, stage 2 in 38 patients, and stage 3 in 28 patients. Lower-body ischemia (the period during circulatory arrest without blood flow to kidneys) duration was not associated with acute kidney injury after multivariable logistic regression (1-40 minutes, odds ratio, 0.67; 95% confidence interval, 0.43-1.04; P = .075; >40 minutes, odds ratio, 0.67; 95% confidence interval, 0.29-1.55; P = .356). Hypertension (odds ratio, 1.65; 95% confidence interval, 1.09-2.54; P = .020), preoperative estimated glomerular filtration rate (odds ratio, 0.99; 95% confidence interval, 0.98-1.00; P = .010), packed red blood cell transfusion volume (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .028), and nadir temperature (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .013) were independently associated with acute kidney injury after multivariable analysis. Although there was a positive association between lower-body ischemia duration and development of acute kidney injury with univariable cubic spline, the positive curve was flattened after adjustment for the described variables.
Conclusions
Within the range of our clinical practice, prolonged lower-body ischemia duration was not independently associated with postoperative acute kidney injury, whereas nadir temperature was.

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

J Thorac Cardiovasc Surg: 06 Apr 2022; epub ahead of print
Hu D, Blitzer D, Zhao Y, Chan C, ... Patel V, Takayama H
J Thorac Cardiovasc Surg: 06 Apr 2022; epub ahead of print | PMID: 35570021
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Branched versus fenestrated thoracic endovascular aortic repair in the aortic arch: A multicenter comparison.

Hauck SR, Kupferthaler A, Kern M, Rousseau H, ... Loewe C, Funovics MA
Objective
For thoracic endovascular aortic repair of the arch, branched and fenestrated endografts are available with different limitations regarding anatomy and extent of the pathology. Comparisons are lacking in the literature. The aim of this study was to compare the results of 2 currently commercially available devices for branched thoracic endovascular aortic repair and fenestrated thoracic endovascular aortic repair.
Methods
In a retrospective, multicenter cohort study, a consecutive patient series treated with branched thoracic endovascular aortic repair or fenestrated thoracic endovascular aortic repair for aortic arch pathologies was assessed. Baseline characteristics, procedural fenestrated thoracic endovascular aortic repair, and outcome were analyzed. Furthermore, the potential anatomic feasibility of the respective alternate device was assessed on the preoperative computed tomography scans.
Results
The branched thoracic endovascular aortic repair and fenestrated thoracic endovascular aortic repair cohorts consisted of 20 and 34 patients, respectively, with similar comorbidities; indication was aneurysm in 65% and 79%, penetrating aortic ulcer in 20% and 9%, and dissection in the remaining procedures, respectively. Technical success was achieved in all but 1 patient. Perioperative mortality and major stroke rate were both 10% in branched thoracic endovascular aortic repair and 0% and 3% in fenestrated thoracic endovascular aortic repair, respectively. During follow-up of 31 and 40 months, 1 branch occlusion occurred in the branched thoracic endovascular aortic repair cohort, and 2 late endoleaks occurred in the fenestrated thoracic endovascular aortic repair group. One aortic death occurred. Although 35% of patients undergoing branched thoracic endovascular aortic repair were anatomically suitable for fenestrated thoracic endovascular aortic repair, 91% of those undergoing fenestrated thoracic endovascular aortic repair were suitable for branched thoracic endovascular aortic repair.
Conclusions
Both branched thoracic endovascular aortic repair and fenestrated thoracic endovascular aortic repair show excellent technical success and acceptable complication rates, whereas branched thoracic endovascular aortic repair tends toward higher morbidity, especially stroke rates. By offering fenestrated thoracic endovascular aortic repair along with branched thoracic endovascular aortic repair, aortic centers could potentially lower complication rates and simultaneously still treat a wide range of anatomies.

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

J Thorac Cardiovasc Surg: 06 Apr 2022; epub ahead of print
Hauck SR, Kupferthaler A, Kern M, Rousseau H, ... Loewe C, Funovics MA
J Thorac Cardiovasc Surg: 06 Apr 2022; epub ahead of print | PMID: 35534283
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cumulative comorbid conditions influence mortality risk after staged palliation for hypoplastic left heart syndrome and variants.

Backes ER, Afonso NS, Guffey D, Tweddell JS, ... Anderson JB, Ghanayem NS
Objective
Prematurity, low birth weight, genetic syndromes, extracardiac conditions, and secondary cardiac lesions are considered high-risk conditions associated with mortality after stage 1 palliation. We report the impact of these conditions on outcomes from a prospective multicenter improvement collaborative.
Methods
The National Pediatric Cardiology Quality Improvement Collaborative Phase II registry was queried. Comorbid conditions were categorized and quantified to determine the cumulative burden of high-risk diagnoses on survival to the first birthday. Logistic regression was applied to evaluate factors associated with mortality.
Results
Of the 1421 participants, 40% (575) had at least 1 high-risk condition. The aggregate high-risk group had lower survival to the first birthday compared with standard risk (76.2% vs 88.1%, P < .001). Presence of a single high-risk diagnosis was not associated with reduced survival to the first birthday (odds ratio, 0.71; confidence interval, 0.49-1.02, P = .066). Incremental increases in high-risk diagnoses were associated with reduced survival to first birthday (odds ratio, 0.23; confidence interval, 0.15-0.36, P < .001) for 2 and 0.17 (confidence interval, 0.10-0.30, P < .001) for 3 to 5 high-risk diagnoses. Additional analysis that included prestage 1 palliation characteristics and stage 1 palliation perioperative variables identified multiple high-risk diagnoses, poststage 1 palliation extracorporeal membrane oxygenation support (odds ratio, 0.14; confidence interval, 0.10-0.22, P < .001), and cardiac reoperation (odds ratio, 0.66; confidence interval, 0.45-0.98, P = .037) to be associated with reduced survival odds to the first birthday.
Conclusions
The presence of 1 high-risk diagnostic category was not associated with decreased survival at 1 year. Cumulative diagnoses across multiple high-risk diagnostic categories were associated with decreased odds of survival. Further patient accrual is needed to evaluate the impact of specific comorbid conditions within the broader high-risk categories.

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

J Thorac Cardiovasc Surg: 02 Apr 2022; epub ahead of print
Backes ER, Afonso NS, Guffey D, Tweddell JS, ... Anderson JB, Ghanayem NS
J Thorac Cardiovasc Surg: 02 Apr 2022; epub ahead of print | PMID: 35599210
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Clinical features and outcomes of unplanned single lung transplants.

Terada Y, Takahashi T, Hachem RR, Liu J, ... Kreisel D, Puri V
Objective
The decision to perform single lung transplants or double lung transplants is usually made before the operation. We have previously reported that a proportion of single lung transplants were unexpectedly performed in the setting of an aborted double lung transplant, and these patients may be at a higher risk of worse short-term outcomes. Long-term outcomes in unplanned single lung transplants remain unknown.
Methods
We analyzed a single-center database of lung transplants from 2000 to 2020. Single lung transplants were classified into planned and unplanned groups after reviewing operative notes. Root cause analysis was performed for unplanned single lung transplants.
Results
Of the 1326 lung transplants, 1265 (95%) were double lung transplants and 61 (5%) were single lung transplants (22 planned [36%], 39 unplanned [64%]). Underlying indications for transplant were significantly different; planned single lung transplant: chronic obstructive pulmonary disease (55%) and idiopathic pulmonary fibrosis (45%); unplanned single lung transplants: chronic obstructive pulmonary disease (23%), idiopathic pulmonary fibrosis (39%), and bronchiolitis obliterans syndrome (13%). The primary reasons for unplanned single lung transplant were donor-related (3, 7.7%), recipient-related (31, 80%), and donor and recipient-related factors (5, 13%). Unplanned single lung transplants were more likely to require cardiopulmonary bypass during the operation (planned: 4/22, 18% vs unplanned: 20/39, 51%) but had shorter ischemic times (planned: 251 ± 58 minutes vs unplanned: 221 ± 48 minutes). The 5-year overall survival was 53% in the planned and 58% in the unplanned groups, respectively (P = .323). No difference in chronic lung allograft dysfunction-free survival (P = .995) was observed.
Conclusions
Unplanned single lung transplants in the setting of aborted double lung transplant may be associated with acceptable long-term outcomes.

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

J Thorac Cardiovasc Surg: 01 Apr 2022; epub ahead of print
Terada Y, Takahashi T, Hachem RR, Liu J, ... Kreisel D, Puri V
J Thorac Cardiovasc Surg: 01 Apr 2022; epub ahead of print | PMID: 35487803
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Positron emission tomography/computed tomography differentiates resectable thymoma from anterior mediastinal lymphoma.

Byrd CT, Trope WL, Bhandari P, Konsker HB, ... Berry MF, Shrager JB
Objective
Discrete anterior mediastinal masses most often represent thymoma or lymphoma. Lymphoma treatment is nonsurgical and requires biopsy. Noninvasive thymoma is ideally resected without biopsy, which may potentiate pleural metastases. This study sought to determine if clinical criteria or positron emission tomography/computed tomography could accurately differentiate the 2, guiding a direct surgery versus biopsy decision.
Methods
A total of 48 subjects with resectable thymoma and 29 subjects with anterior mediastinal lymphoma treated from 2006 to 2019 were retrospectively examined. All had pretreatment positron emission tomography/computed tomography and appeared resectable (solitary, without clear invasion or metastasis). Reliability of clinical criteria (age and B symptoms) and positron emission tomography/computed tomography maximum standardized uptake value were assessed in differentiating thymoma and lymphoma using Wilcoxon rank-sum test, chi-square test, and logistic regression. Receiver operating characteristic analysis identified the maximum standardized uptake value threshold most associated with thymoma.
Results
There was no association between tumor type and age group (P = .183) between those with thymoma versus anterior mediastinal lymphoma. Patients with thymoma were less likely to report B symptoms (P < .001). The median maximum standardized uptake value of thymoma and lymphoma differed dramatically: 4.35 versus 18.00 (P < .001). Maximum standardized uptake value was independently associated with tumor type on multivariable regression. On receiver operating characteristic analysis, lower maximum standardized uptake value was associated with thymoma. Maximum standardized uptake value less than 12.85 was associated with thymoma with 100.00% sensitivity and 88.89% positive predictive value. Maximum standardized uptake value less than 7.50 demonstrated 100.00% positive predictive value for thymoma.
Conclusions
Positron emission tomography/computed tomography maximum standardized uptake value of resectable anterior mediastinal masses may help guide a direct surgery versus biopsy decision. Tumors with maximum standardized uptake value less than 7.50 are likely thymoma and thus perhaps appropriately resected without biopsy. Tumors with maximum standardized uptake value greater than 7.50 should be biopsied to rule out lymphoma. Lymphoma is likely with maximum standardized uptake value greater than 12.85.

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

J Thorac Cardiovasc Surg: 01 Apr 2022; epub ahead of print
Byrd CT, Trope WL, Bhandari P, Konsker HB, ... Berry MF, Shrager JB
J Thorac Cardiovasc Surg: 01 Apr 2022; epub ahead of print | PMID: 35568521
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Late outcomes of surgical reconstruction of peripheral pulmonary arteries.

Al-Khaldi A, Abuzaid AD, Tamimi O, Alsahari A, ... Momenah T, Alfonso JJ
Objective
The ideal management of peripheral pulmonary artery stenosis is still controversial. We adopted a primary surgical approach to this complex lesion with excellent early outcomes. In this study, we analyzed our late outcomes.
Methods
We performed a retrospective review of 91 patients with biventricular anatomy who underwent peripheral pulmonary artery reconstruction from March 2008 to July 2020. Our surgical approach included either a single-stage complete repair through median sternotomy or a 2-stage repair through sternotomy/left thoracotomy, depending on the degree of distal involvement of the left pulmonary artery branches.
Results
Median age was 26 months. Syndromic etiology was established in 54 patients (59.3%) versus nonsyndromic etiology in 37 patients (40.7%). Single-stage repair was achieved in 68 patients (74.7%). There were 2 (2.2%) in-hospital mortalities. The mean right ventricular to aortic systolic pressure ratio decreased from 1.07 ± 0.20 preoperatively to 0.32 ± 0.07 immediately postoperatively (P < .001), representing a 70.1% reduction. At 1-year postoperative catheterization, the mean right ventricular to aortic systolic pressure ratio was 0.28 ± 0.05 (P < .001 compared with immediately postoperative value). With a median follow-up of 68 months (IQR, 39-117.5 months), there was no late mortality after discharge. All patients were active and asymptomatic on the most recent follow-up. There were no early or late reinterventions on pulmonary arteries.
Conclusions
Late outcomes of surgical reconstruction of peripheral pulmonary arteries are excellent and durable in various pathologies (syndromic and nonsyndromic) with a significant reduction in right ventricular to aortic systolic pressure ratio, low mortality, and no reintervention.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 31 Mar 2022; 163:1448-1457.e6
Al-Khaldi A, Abuzaid AD, Tamimi O, Alsahari A, ... Momenah T, Alfonso JJ
J Thorac Cardiovasc Surg: 31 Mar 2022; 163:1448-1457.e6 | PMID: 34649717
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Outcomes of pleurectomy decortication in patients with biphasic mesothelioma.

Lapidot M, Mazzola E, Bueno R
Objective
There are limited small, single-institution observational studies on the role of surgery in patients with biphasic mesothelioma. Herein we report a series of 147 consecutive patients with biphasic mesothelioma treated over 11 years in a high-volume single institution with intended pleurectomy decortication (PDC).
Methods
All patients with biphasic mesothelioma from 2007 to 2017 who underwent PDC in our institution were included and clinical, pathologic, and surgical information was retrieved. Kaplan-Meier estimators and log rank test were used to compare the overall survival, and Cox regression models were used to analyzed prognostic factors.
Results
There were 117 men (80%), 99 right-sided operations (67%), and median age was 70 (range, 36-86) years. Neoadjuvant therapy was given to 36 (24.5%) and 108 (73.5%) received intraoperative heated chemotherapy. Macroscopic complete resection was achieved in 126 (86%). Tumors were assigned to stages IA (23; 18.8%), IB (60; 47.5%) II (15; 11.5%), IIIA (17; 13.1%), and IIIB (11; 9%) according to the eighth edition of the tumor-node-metastasis classification of malignant tumors. The 30- and 90-day mortality were 1.3% and 6.1%, respectively. The median overall survival in the macroscopic complete resection group was 16.7 months and 24 months in patients younger than 70 years. In a univariate analysis, factors that were associated with patient overall survival included age (P = .001), preoperative percentage forced expiratory volume in 1 second (P = .019), and adjuvant therapy (P < .001). No correlation was found between sex, neoadjuvant therapy, and nodal status to overall survival.
Conclusions
In selected patients with biphasic mesothelioma and good prognostic factors prolonged survival after PDC is expected.

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

J Thorac Cardiovasc Surg: 30 Mar 2022; epub ahead of print
Lapidot M, Mazzola E, Bueno R
J Thorac Cardiovasc Surg: 30 Mar 2022; epub ahead of print | PMID: 35513907
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Selective sinus replacement for aortic root repair in bicuspid aortopathy.

Urbanski PP, Atieh A, Lehmkuhl L, Irimie V, ... Nasra W, Diegeler A
Objectives
To evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy.
Methods
Among 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation.
Results
Abolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary.
Conclusions
Patient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.

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

J Thorac Cardiovasc Surg: 30 Mar 2022; epub ahead of print
Urbanski PP, Atieh A, Lehmkuhl L, Irimie V, ... Nasra W, Diegeler A
J Thorac Cardiovasc Surg: 30 Mar 2022; epub ahead of print | PMID: 35461710
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Patient-specific severity of von Willebrand factor degradation identifies patients with a left ventricular assist device at high risk for bleeding.

Hennessy-Strahs S, Kang J, Krause E, Dowling RD, Rame JE, Bartoli CR
Background
Continuous-flow left ventricular assist devices (LVADs) cause an acquired von Willebrand factor (VWF) deficiency and bleeding. Models to risk-stratify for bleeding are urgently needed. We developed a model of continuous-flow LVAD bleeding risk from patient-specific severity of VWF degradation.
Methods
In a prospective, longitudinal cohort study, paired blood samples were obtained from patients (n = 67) with a continuous-flow LVAD before and during support. After 640 ± 395 days, patients were categorized as all-cause bleeders, gastrointestinal (GI) bleeders, or nonbleeders. VWF multimers and VWF clotting function were evaluated to determine bleeding risk.
Results
Of 67 patients, 34 (51%) experienced bleeding, 26 (39%) experienced GI bleeding, and 33 (49%) did not bleed. In all patients, LVAD support significantly reduced high-molecular-weight VWF multimers (P < .001). Bleeders exhibited greater loss of high-molecular-weight VWF multimers (mean ± standard deviation, -10 ± 5% vs -7 ± 4%, P = .008) and reduced VWF clotting function versus nonbleeders (median [interquartile range], -12% [-31% to 4%] vs 0% [-9 to 26%], P = .01). A combined metric of VWF multimers and VWF function generated the All-Cause Bleeding Risk Score, which stratified bleeders versus nonbleeders (86 ± 56% vs 41 ± 48%, P < .001) with a positive predictive value of 86% (95% confidence interval, 66%-95%) and diagnostic odds ratio of 11 (95% confidence interval, 2.9-44). A separate GI Bleeding Risk Score stratified GI bleeders versus nonbleeders (202 ± 114 vs 120 ± 86, P = .003) with a positive predictive value of 88% (64%-97%) and diagnostic odds ratio of 18 (3.1-140).
Conclusions
The severity of loss of VWF multimers and VWF clotting function generated Bleeding Risk Scores with high predictive value for LVAD-associated bleeding. This model may guide personalized antithrombotic therapy and patient surveillance.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 30 Mar 2022; epub ahead of print
Hennessy-Strahs S, Kang J, Krause E, Dowling RD, Rame JE, Bartoli CR
J Thorac Cardiovasc Surg: 30 Mar 2022; epub ahead of print | PMID: 35501195
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Treatment strategies and in-hospital mortality in patients with type A acute aortic dissection and coronary artery involvement.

Hashimoto O, Saito Y, Sasaki H, Yumoto K, ... Yasuda S, Angina Pectoris-Myocardial Infarction Multicenter Investigators
Objective
Type A acute aortic dissection (AAD), especially that with coronary artery involvement and malperfusion, is a life-threatening disease. In the present study we aimed to investigate the association of surgical treatment and percutaneous coronary intervention (PCI) with in-hospital mortality in patients with type A AAD and coronary artery involvement.
Methods
This retrospective multicenter registry in Japan included 225 patients with type A AAD and coronary artery involvement. Treatment strategies including surgical treatment and/or PCI were left to treating physicians. The primary end point was in-hospital death.
Results
Of 225 patients, dissection extended into the right and left coronary arteries and both in 115 (51.1%), 105 (46.7%), and 5 (2.2%), respectively. Overall, 94 (41.8%) patients died during the hospitalization. Coronary angiography was performed in 53 (23.6%) patients, among whom 39 (73.6%) underwent PCI. Surgical repair was performed in 188 (83.6%) patients. In patients who received neither procedure, 33 of 35 (94.3%) died during the hospitalization. PCI was performed as a bridge to surgical repair in 37 of 39 (94.9%) patients, and in-hospital mortality of patients who underwent PCI and surgical procedures was 24.3%. Multivariable analysis identified PCI and surgical procedures as factors associated with lower in-hospital mortality rates.
Conclusions
Coronary artery involvement in type A AAD was associated with high in-hospital mortality of more than 40% in the current era. An early reperfusion strategy with PCI as a bridge to surgical repair might improve clinical outcomes in this fatal condition.

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

J Thorac Cardiovasc Surg: 29 Mar 2022; epub ahead of print
Hashimoto O, Saito Y, Sasaki H, Yumoto K, ... Yasuda S, Angina Pectoris-Myocardial Infarction Multicenter Investigators
J Thorac Cardiovasc Surg: 29 Mar 2022; epub ahead of print | PMID: 35459537
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Impact of proinflammatory epicardial adipose tissue and differentially enhanced autonomic remodeling on human atrial fibrillation.

Zhao J, Zhang Y, Yin Z, Zhu Y, ... Po SS, Wang H
Objectives
The mechanisms underlying atrial fibrillation are yet to be elucidated. We sought to investigate the interactions among autonomic remodeling, epicardial adipose tissue, inflammation, and atrial fibrillation.
Methods
Myocardium and adjacent epicardial adipose tissue of the left atrial appendage, right atrial appendage, and pulmonary vein muscle sleeves were obtained from 61 consecutive patients (35 with atrial fibrillation, 26 with no atrial fibrillation) during mitral valve surgeries. Patients were divided into the atrial fibrillation group and no atrial fibrillation group according to the history and Holter monitoring before surgery. Sympathetic and parasympathetic innervation were evaluated by tyrosine hydroxylase and choline acetyltransferase staining, respectively. Atrial fibrosis as well as cytokines/adipokines and related inflammatory proteins and signaling pathways in the epicardial adipose tissue were examined.
Results
Immunohistochemical studies revealed significantly increased tyrosine hydroxylase (+) and choline acetyltransferase (+) neural elements in the left atrial appendage and pulmonary vein muscle sleeve myocardium, as well as adjacent epicardial adipose tissue in the atrial fibrillation group, particularly the pulmonary vein muscle sleeve sites. The receiver operating curve identified a threshold ratio (tyrosine hydroxylase/choline acetyltransferase) of 0.8986 in the epicardial adipose tissue (sensitivity = 82.86%; specificity = 80.77%; area under the curve = 0.85, 95% confidence interval = 0.76-0.95, P < .0001). More patients with a higher tyrosine hydroxylase/choline acetyltransferase ratio (≥0.8986) had atrial fibrillation. Expression levels of the genes and related proteins of the β1 adrenergic, mitogen-activated protein kinase, and nuclear factor kappa B signaling pathways were higher in patients with a higher tyrosine hydroxylase/choline acetyltransferase ratio. The tyrosine hydroxylase/choline acetyltransferase ratio also correlated with fibrosis.
Conclusions
Differentially enhanced autonomic remodeling and proinflammatory and profibrotic cytokines/adipokines in the epicardial adipose tissue adjacent to the pulmonary vein muscle sleeve site may work synergistically to promote atrial fibrillation.

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

J Thorac Cardiovasc Surg: 28 Mar 2022; epub ahead of print
Zhao J, Zhang Y, Yin Z, Zhu Y, ... Po SS, Wang H
J Thorac Cardiovasc Surg: 28 Mar 2022; epub ahead of print | PMID: 35461705
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Impact of preprocedural mesenteric artery stenosis and mesenteric ischemia in patients undergoing transcatheter aortic valve replacement.

Chen JH, Chen YH, Chang HH, Leu HB, ... Chen PL, Lin SM
Objectives
We aimed to examine the incidence, etiologies, and consequences of acute mesenteric ischemia as well as the impact of preprocedural subclinical mesenteric artery stenosis in patients undergoing transcatheter aortic valve replacement.
Methods
Among prospective follow-up of 269 consecutive patients undergoing transcatheter aortic valve replacement, diagnosis of acute mesenteric ischemia was confirmed by abdominal computed tomography. Cumulative hazard of 1-year all-cause and cardiovascular mortality according to the absence or presence of mesenteric artery stenosis 70% or greater from preprocedural computed tomography angiography was analyzed.
Results
Acute mesenteric ischemia was confirmed in 7 patients (2.6%) during mid-term (median, 33.3 months, interquartile range, 15.0-61.0 months) follow-up. Thrombotic occlusions of previously stenotic mesenteric arteries account for 4 cases (57.1%), and embolic acute mesenteric ischemia constitute the rest (42.9%) of the cases. The mortality rate of acute mesenteric ischemia was 100%. At 30 days, death from acute mesenteric ischemia accounts for 40% of all-cause mortality and 67% of cardiovascular death. By multivariable analysis, higher Society of Thoracic Surgeons score and mesenteric artery stenosis 70% or greater were independently associated with acute mesenteric ischemia. Thirty-two patients (11.9%) with preprocedural mesenteric artery stenosis 70% or greater had an increased risk of all-cause mortality (adjusted hazard ratio, 3.78; 95% confidence interval, 1.74-8.19; P = .001) at 1 year after transcatheter aortic valve replacement.
Conclusions
Acute mesenteric ischemia, an important cause of 30-day mortality, should be considered in patients who become clinically unstable after transcatheter aortic valve replacement, particularly but not exclusively in those with preexisting mesenteric artery stenosis. Mesenteric artery stenosis should be routinely assessed in all patients who are indicated for transcatheter aortic valve replacement considering the dismal prognosis of acute mesenteric ischemia.

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

J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print
Chen JH, Chen YH, Chang HH, Leu HB, ... Chen PL, Lin SM
J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print | PMID: 35469598
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Ex vivo lung evaluation of single donor lungs when the contralateral lung is rejected increases safe use.

Dunne B, Pozniak J, Campo-Canaveral de la Cruz JL, Lemaitre P, ... Cypel M, Yeung JC
Objective
The decision to perform a single-lung transplant (SLT) when the contralateral donor lung is rejected is a challenging scenario. The introduction of ex vivo lung perfusion (EVLP) has improved donor lung assessment, and we hypothesize that it has improved SLT outcomes in this setting.
Methods
A retrospective single-center review of all SLTs performed between 2000 and 2017 was performed in which the years 2000 to 2008 were considered the \"pre-EVLP era\" and 2009 to 2017 the \"EVLP era.\" Recipients of SLT lungs when the contralateral lung was declined were classified into 3 groups: (1) Pre-EVLP era, (2a) EVLP era but EVLP not used, and (2b) EVLP era and EVLP used. The outcomes of interest were survival, time-to-extubation, and intensive care unit and hospital stay.
Results
Among 1692 transplants between 2000 and 2017, 244 (14%) were SLT. SLT rate was similar between eras (pre-EVLP 16% vs EVLP 15%), but more SLTs were performed where the contralateral lung was declined in the EVLP era (pre-EVLP 32% vs EVLP 45%, P = .04). Lungs evaluated on EVLP had lower procurement partial pressure of oxygen and were more often from donation after cardiac death donors. Recipients were generally also sicker, with a greater proportion of rapidly deteriorating recipients. Despite this, outcomes were similar between eras with a trend towards lower 30-day mortality in the EVLP era.
Conclusions
The availability of EVLP allowed for better evaluation of marginal single lungs when the contralateral was declined. This has led to increased use rates with preserved outcomes despite use of more extended criteria organs.

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

J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print
Dunne B, Pozniak J, Campo-Canaveral de la Cruz JL, Lemaitre P, ... Cypel M, Yeung JC
J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print | PMID: 35469599
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Assessing donor organ quality according to recipient characteristics in lung transplantation.

Wadowski B, Chang SH, Carillo J, Angel L, Kon ZN
Objective
There is a shortage of donor lungs relative to need, but overall donor organ utilization remains low. The most common reason for refusal is organ quality, but the standards applied to selection vary. In this study we sought to characterize differences in lung utilization according to quality across several clinically distinct recipient pools.
Methods
Data on donor lungs recovered (April 2006 to September 2019) were extracted from the Scientific Registry of Transplant Recipients database. Organs were classified as ideal, standard, or extended quality according to their poorest metric among selected parameters. Subanalyses were performed on the basis of procedure type, age, lung allocation score, era, and alternative definitions of extended quality. Recipient traits and survival according to organ quality were assessed.
Results
Of 156,022 lungs analyzed during the study period, 25,777 (16.5%) were transplanted. There was no difference in quality distribution for single and bilateral transplants. Young candidates were more likely to receive ideal (14.7% vs 12.3%) or standard (9.5% vs 8.2%) lungs, but not extended lungs (75.9% vs 79.5%; all P < .01). Absolute differences in distribution according to lung allocation score quartile were small (<2%). Extended quality donor utilization increased over time. Survival according to donor category was similar at 1 and 3 years post transplant in unadjusted and Cox regression analyses.
Conclusions
Extended quality lungs comprise an increasing share of transplants in a national sample. Organ selection varies according to recipient age and lung allocation score. However, absolute differences in quality distribution are small, and adverse effects on outcomes are limited to organs with multiple extended qualifying characteristics.

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

J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print
Wadowski B, Chang SH, Carillo J, Angel L, Kon ZN
J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print | PMID: 35461708
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Aortic valve versus root surgery after failed transcatheter aortic valve replacement.

Vitanova K, Zaid S, Tang GHL, Kaneko T, ... Denti P, EXPLANT-TAVR Investigators
Objective
We sought to determine outcomes of aortic valve replacement (AVR) versus root replacement after transcatheter AVR (TAVR) explantation because they remain unknown.
Methods
From November 2009 to September 2020, data from the EXPLANT-TAVR International Registry of patients who underwent TAVR explant were retrospectively reviewed, divided by AVR versus root replacement. After excluding explants performed during the same admission as the initial TAVR and concomitant procedures involving the other valves, 168 AVR cases were compared with 28 root replacements, and outcomes were reported at 30 days and 1 year.
Results
Among 196 patients (mean age, 73.5 ± 9.9 years) who had primary aortic valve intervention at TAVR explant, the median time from TAVR to surgical explant was 11.2 months (interquartile range, 4.4-32.9 months). Indications for explant were similar between the 2 groups. Compared with AVR, patients requiring root replacement had fewer comorbidities but more unfavorable anatomy for redo TAVR (52.6% vs 26.4%; P = .032), fewer urgent/emergency cases (32.1% vs 58.3%; P = .013), longer median interval from index TAVR to TAVR explant (17.6 vs 9.9 months; P = .047), and more concomitant ascending aortic replacement (58.8% vs 14.0%; P < .001). Median follow-up was 6.9 months (interquartile range, 1.4-21.6 months) after TAVR explant and 97.4% complete. Overall survival at follow-up was 81.2% with no differences between groups (log rank P = .54). In-hospital, 30-day, and 1-year mortality rates and stroke rates were not different between the 2 groups.
Conclusions
In the EXPLANT-TAVR Registry, AVR and root replacement groups had different clinical characteristics, but no differences in short-term mortality and morbidities. Further investigations are necessary to identify patients at risk of root replacement in TAVR explant.

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

J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print
Vitanova K, Zaid S, Tang GHL, Kaneko T, ... Denti P, EXPLANT-TAVR Investigators
J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print | PMID: 35525801
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Endobronchial ultrasound-guided bipolar radiofrequency ablation for lung cancer: A first-in-human clinical trial.

Ishiwata T, Motooka Y, Ujiie H, Inage T, ... Pal P, Yasufuku K
Objective
Percutaneous radiofrequency ablation (RFA) is a therapeutic option for lung tumors. However, percutaneous approaches have limited access to central lung regions and a relatively high complication rate. To overcome these limitations, a needle-type bipolar RFA device compatible with an endobronchial ultrasound (EBUS) bronchoscope was developed. The aim of this pilot study was to evaluate the immediate-term safety and ablation zone of lung tumor EBUS-guided RFA.
Methods
This was an ablate-and-resect study in patients scheduled for surgical resection of clinical stage I or II lung cancer or metastatic lung lesions ≥1 cm that were accessible using an EBUS bronchoscope. The RFA electrodes were placed within the lung nodule using EBUS guidance followed by ablation. Bronchoscopy and contrast-enhanced computed tomography were performed to evaluate for post-RFA complications. The resected lung underwent pathological assessment to characterize the ablation zone.
Results
A total of 5 primary lung cancers were ablated in 5 separate patients; no patients with metastatic lesions were recruited. For a total energy of 4 kJ (n = 3), 6 kJ (n = 1), and 8 kJ (n = 1) delivered, the ablation time was a mean of 13.8 (range, 10.3-16.0) minutes, 8.4 minutes, and 15.6 minutes, respectively, and the maximum ablation diameter was a mean of 1.8 (range, 1.3-2.1) cm, 2.7 cm, and 2.6 cm, respectively. No immediate post-RFA complications were observed.
Conclusions
EBUS-guided bipolar RFA can ablate lung tumors using real-time ultrasound guidance. EBUS-guided RFA might ultimately represent a minimally invasive therapy for lung cancer in patients unable to tolerate surgery. Longer-term safety will need to be evaluated.

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

J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print
Ishiwata T, Motooka Y, Ujiie H, Inage T, ... Pal P, Yasufuku K
J Thorac Cardiovasc Surg: 26 Mar 2022; epub ahead of print | PMID: 35459539
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Integrated cardiothoracic surgery match: Trends among applicants compared with other surgical subspecialties.

Bougioukas L, Heiser A, Berg A, Polomsky M, Rokkas C, Hirashima F
Objective
The objective of this study was to evaluate trends, qualifications, race/ethnicity, and gender of applicants to integrated cardiothoracic (CT I-6) residency programs and compare them with other competitive surgical subspecialties.
Methods
Data were collected from the National Residency Matching Program, Electronic Residency Application Service, and Association of American Medical Colleges for thoracic surgery, orthopedic surgery, neurological surgery, otolaryngology (ENT), plastic surgery, and vascular surgery for 2010 t0 2020. Applicant gender, race/ethnicity, Alpha Omega Alpha (AOA) membership, United States Medical Licensing Examination scores, research productivity, and graduation from a top-40 medical school were analyzed.
Results
From 2010 to 2020, CT I-6 experienced growth in postgraduate year 1 positions (280.0%), total applicants (62.2%), and US senior applicants (59.2%). No growth in CT I-6 positions (38) or programs (29) occurred from 2016 to 2020. CT I-6 had the lowest match rates among total applicants (31.7%) and US seniors (41.0%) in 2020. CT I-6 had fewer female applicants compared with ENT (P < .001) and plastic surgery (P < .001), but more than orthopedic surgery (P < .001). Although most CT I-6 US applicants self-identified as White (75.0%), there were more Asian applicants compared with applicants for orthopedic surgery (P < .001), ENT (P < .001), plastic surgery (P < .001), and neurological surgery (P < .01). Matched applicants averaged the highest Step 2-Clinical Knowledge scores (255.1), AOA membership (48.5%), and graduation rates from top-40 medical schools (54.5%).
Conclusions
Despite tremendous growth in positions, CT I-6 has consistently been the most difficult surgical subspecialty to match. CT I-6 has recently attracted an increasingly diverse applicant pool. For the 2019 to 2020 National Residency Matching Program Match Cycle, successful applicants had the highest Step 2-Clinical Knowledge scores, AOA membership rates, and graduation rates from a top-40 medical school among all surgical subspecialties examined.

Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 22 Mar 2022; epub ahead of print
Bougioukas L, Heiser A, Berg A, Polomsky M, Rokkas C, Hirashima F
J Thorac Cardiovasc Surg: 22 Mar 2022; epub ahead of print | PMID: 35461707
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

A potential mechanism by which aspiration of duodenogastric fluid augments the risk for bronchiolitis obliterans syndrome after lung transplantation.

Olson MT, Liu W, Mohanakumar T, Bremner RM
Objective
Aspiration of duodenogastric refluxate may damage the respiratory epithelium of lung allografts in transplant recipients. We sought to define a mechanism by which aspiration of duodenogastric fluid augments the risk of bronchiolitis obliterans syndrome after lung transplant in a murine model.
Methods
We analyzed the immunological effects of acute aspiration of duodenogastric fluid (0.5 mL/kg) on transplant naive (strain DBA/2J) and transplanted mice (strain B6D2F1/J to strain DBA/2J). Serum antibodies to the lung self-antigens (SAgs) K-alpha1 tubulin and collagen-V were determined by enzyme-linked immunosorbent assay. Exosomes were isolated from serum, and immunoblot membranes were probed for antibodies to lung SAgs. Lung sections were assessed for fibrotic burden and obliterative bronchiolitis lesions by histologic and immunohistochemical analyses, including trichrome staining.
Results
Transplanted mice that received duodenogastric fluid developed higher levels of antibodies to the lung SAgs K-alpha1 tubulin and collagen-V and exosomes with lung SAgs on posttransplant days 14 and 28 than transplanted mice with sham aspiration or transplant naive mice (with and without aspiration). All lung allografts demonstrated severe grade A4 rejection on posttransplant day 14, with the highest mean fibrotic burden and mean number of obliterative bronchiolitis-like lesions per microscopic field on day 28 in recipients with aspiration.
Conclusions
This study links aspiration of duodenogastric fluid after lung transplant to higher autoimmune responses to lung SAgs and the release of circulating exosomes with lung SAgs, which together promote sustained immune responses leading to extensive lung parenchymal damage and, ultimately, severe obliterative bronchiolitis-the histologic hallmark of bronchiolitis obliterans syndrome.

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

J Thorac Cardiovasc Surg: 21 Mar 2022; epub ahead of print
Olson MT, Liu W, Mohanakumar T, Bremner RM
J Thorac Cardiovasc Surg: 21 Mar 2022; epub ahead of print | PMID: 35428458
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Bilateral internal thoracic artery versus single internal thoracic artery plus radial artery: A double meta-analytic approach.

Urso S, Sadaba R, González Martín JM, Nogales E, Tena MÁ, Portela F
Objectives
We explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery.
Methods
PubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan-Meier-derived individual patient data.
Results
Twelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan-Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93).
Conclusions
The present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. VIDEO ABSTRACT.

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

J Thorac Cardiovasc Surg: 21 Mar 2022; epub ahead of print
Urso S, Sadaba R, González Martín JM, Nogales E, Tena MÁ, Portela F
J Thorac Cardiovasc Surg: 21 Mar 2022; epub ahead of print | PMID: 35437176
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The impact of perioperative stroke and delirium on outcomes after surgical aortic valve replacement.

Messé SR, Overbey JR, Thourani VH, Moskowitz AJ, ... Browndyke JN, Cardiothoracic Surgical Trials Network (CTSN) Investigators
Objective
The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days.
Methods
Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life.
Results
By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score >2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference -3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference -2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01).
Conclusions
Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 18 Mar 2022; epub ahead of print
Messé SR, Overbey JR, Thourani VH, Moskowitz AJ, ... Browndyke JN, Cardiothoracic Surgical Trials Network (CTSN) Investigators
J Thorac Cardiovasc Surg: 18 Mar 2022; epub ahead of print | PMID: 35483981
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Outcomes of the arterial switch operation in patients with inverted coronary artery anatomy.

Fricke TA, Buratto E, Thungathurthi K, Schulz A, ... Brizard CP, Konstantinov IE
Objective
Patients undergoing the arterial switch operation (ASO) with inverted coronary anatomy represent a technical challenge. We sought to determine the long-term outcomes of patients with inverted coronary anatomy who underwent an ASO.
Methods
A retrospective analysis of patients who underwent an ASO with inverted coronary anatomy at a single institution was performed and comparison was made between patients with inverted and normal coronary anatomy.
Results
There were 43 (5.1% [43 out of 844]) patients with inverted coronary anatomy. Twenty patients (46.5% [20 out of 43]) had a right coronary artery that arises from sinus 1 and the left anterior descending and circumflex coronaries arise from sinus 2 anatomy and 23 (53.5% [23 out of 43]) patients with right coronary artery that arises from sinus 1 and gives rise to the left anterior descending with the circumflex coronaries arising from sinus 2. Median follow-up was 17 years (interquartile range, 12-21 years). Overall early mortality was 7.0% (3 out of 43) compared with 3.1% (17 out of 556) in patients with normal coronary anatomy undergoing operation over the same time period (P = .17). There were 2 (10% [2 out of 20]) early deaths in the right coronary artery that arises from sinus 1 and gives rise to the left anterior descending with the circumflex coronaries arising from sinus 2 group and 1 (4.3% [1 out of 23]) early death in the right coronary artery that arises from sinus 1 and the left anterior descending and circumflex coronaries arise from sinus 2 group. There was 1 late death occurring at 40 days after ASO. Nine (23% [9 out of 39]) patients had 15 reinterventions occurring at median 3.6 years (interquartile range, 1.1-8.2 years). The most common cause of reintervention was main or branch pulmonary artery stenosis (15% [6 out of 39]). Freedom from reintervention was 78% (95% CI, 68%-93%) and 75% (95% CI, 56%-86%) at 10 and 15 years, respectively. At final follow-up, all surviving local patients except 1 was in New York Heart Association functional class I.
Conclusions
Patients with inverted coronary anatomy who underwent an ASO had a higher mortality but this was not statistically significant. However, there were no coronary reinterventions in survivors.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Fricke TA, Buratto E, Thungathurthi K, Schulz A, ... Brizard CP, Konstantinov IE
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35400493
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Clinical significance of left tracheobronchial lymph node dissection in thoracic esophageal squamous cell carcinoma.

Xu L, Wei XF, Chen XK, Qi S, ... Zhang RX, Li Y
Objective
The left tracheobronchial lymph nodes are considered as regional lymph nodes for esophageal squamous cell carcinoma, but routine prophylactic left tracheobronchial lymph node dissection for all resectable esophageal squamous cell carcinoma has been controversial. This study aimed to evaluate the prognostic impact of left tracheobronchial lymph node dissection and left tracheobronchial lymph node metastases in thoracic esophageal squamous cell carcinoma and to analyze the risk factors of left tracheobronchial lymph node metastases.
Methods
A total of 3522 patients with esophageal squamous cell carcinoma undergoing esophagectomy were included. Overall survival was calculated by a Kaplan-Meier method and compared using the log-rank test. Propensity score matching was conducted to adjust confounding factors. Univariable and multivariable logistic regression analyses were used to identify independent risk factors of left tracheobronchial lymph node metastases.
Results
In this study, 608 patients underwent left tracheobronchial lymph node dissection and 45 patients had left tracheobronchial lymph node metastases (7.4%). After propensity score matching, the 5-year overall survival in patients receiving left tracheobronchial lymph node dissection was better than in patients who did not (68.2% vs 64.6%, P = .012). In patients receiving left tracheobronchial lymph node dissection, patients with left tracheobronchial lymph node metastases had a significantly poorer survival than patients without (5-year overall survival: 40.5% vs 62.2%, P = .029). Multivariable logistic analyses showed that clinical T stage and tumor differentiation were independent risk factors for left tracheobronchial lymph node metastases.
Conclusions
In thoracic esophageal squamous cell carcinoma, station left tracheobronchial lymph node metastases indicate a poor prognosis and left tracheobronchial lymph nodes dissection seems to be associated with a more favorable prognosis. Clinical T stage and tumor differentiation were independent risk factors for left tracheobronchial lymph node metastases. For patients with high risk, routine prophylactic left tracheobronchial lymph node dissection should be performed.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Xu L, Wei XF, Chen XK, Qi S, ... Zhang RX, Li Y
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35400494
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy.

Mahboubi R, Kakavand M, Soltesz EG, Rajeswaran J, ... Svensson LG, Johnston DR
Objective
Increasing use of bioprostheses for surgical aortic valve replacement (SAVR) in younger patients, together with wider use of transcatheter aortic valve replacement, necessitates understanding risks associated with surgical valve reintervention. Therefore, we sought to identify risks of reoperative SAVR compared with those of primary isolated SAVR.
Methods
From January 1980 to July 2017, 7037 patients underwent nonemergency isolated SAVR, with 753 reoperations and 6284 primary isolated operations. These 2 groups were propensity score-matched on 46 preoperative variables, yielding 581 patient pairs for comparing outcomes.
Results
Among propensity score-matched patients, aortic clamp time (median 63 vs 52 minutes; P < .0001), cardiopulmonary bypass time (median 88 vs 67 minutes; P < .0001), and postoperative stay (median 7.1 vs 6.9 days; P = .003) were longer for reoperative SAVR than primary isolated SAVR. Hospital mortality after reoperative SAVR decreased from 3.4% in 1985 to 1.3% in 2011, similar to that of primary isolated SAVR. Occurrence of stroke, deep sternal wound infection, and new renal dialysis was similar. Blood transfusion (67% vs 36%; P < .0001) and reoperations for bleeding/tamponade (6.4% vs 3.1%; P = .009) were more common after reoperative SAVR. Survival at 1, 5, 10, and 20 years was 94%, 82%, 64%, and 33% after reoperative SAVR and 95%, 86%, 72%, and 46% after elective primary isolated SAVR.
Conclusions
Risk of mortality and morbidity after reoperative SAVR has declined and is now similar to that of primary isolated SAVR. Decisions regarding prosthesis choice and SAVR versus transcatheter aortic valve replacement should be made in the context of lifelong disease management rather than avoidance of reoperation.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Mahboubi R, Kakavand M, Soltesz EG, Rajeswaran J, ... Svensson LG, Johnston DR
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35397951
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Optimizing evaluation in pediatric and young adult patients with Marfan syndrome: Novel longitudinal metrics to track growth of aortic structures.

Bhimani SA, Rahmy A, Kim S, Jin JB, ... Najm HK, Klein J
Objective
Surveillance metrics in pediatric and young adult Marfan syndrome (pMFS) are challenging. We evaluated the utility of aortic root cross-sectional area/height index (CSA/Ht) on echocardiogram among pMFS patients as a risk stratification and surgical triage metric.
Methods
Genotype or phenotype positive pMFS patients aged 25 years or younger seen at our center from 2001 to 2020 were identified. Time-related transition to surgery was modeled using parametric methods. Predictive utility of CSA/Ht compared with aortic root diameter (ARd) and root Z score (ARz) were modeled using nonlinear multivariable parametric and nonparametric longitudinal regression models.
Results
Seventy-nine patients (43% female) presented at median age of 5.8 years (15th-85th percentile, 0.75-17 years) with median follow-up of 4.4 years (range, 0-18.5 years). Baseline echocardiography data were: CSA/Ht, 3.9 ± 1.4 cm2/m; ARd, 2.4 ± 0.89 cm; and ARz, 2.4 ± 1.7. CSA/Ht tracked ARd better compared with ARz (r = 0.91 vs 0.24). Eighteen patients underwent surgery. Surgical procedures included at least 2 components in 17 (aortic, mitral, tricuspid, aortic root, and arch procedures) and isolated mitral valve procedures in 1 patient. Time-related transition to surgery showed a prominent early phase to 1 year post presentation, followed by a slowly increasing late phase. CSA/Ht had a more linear correlation versus ARz during periods of rapid somatic growth in surgical patients. Surgical repair occurred at CSA/Ht between 5 and 7 cm2/m.
Conclusions
CSA/Ht tracked ARd well over time. CSA/Ht between 5 and 7 cm2/m might be a promising metric for surgical triage in pMFS patients. CSA/Ht surgical threshold values in pMFS patients occurred at lower than current accepted \"surgical\" threshold values for CSA/Ht in adult Marfan syndrome patients.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Bhimani SA, Rahmy A, Kim S, Jin JB, ... Najm HK, Klein J
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35450696
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Outcomes of lung transplantation at a Canadian center using donors declined in the United States.

Cypel M, Yeung J, Donahoe L, Yasufuku K, ... Waddell TK, Keshavjee S
Objectives
Donor lungs from the United States can be offered by US organ procurement organizations to Canada if no American centers accept them. The purpose of this study is to evaluate outcomes of patients undergoing transplant at a single center in Canada using declined lungs from the United States and to compare these outcomes to patients receiving lungs from Canadian donors.
Methods
A single-center retrospective review of recipients receiving lung transplantation between January 2009 and October 2019 was performed. An Organ Procurement and Transplantation Network standard transplant analysis and research-limited dataset as of August 17, 2021, was provided by the United Network for Organ Sharing. De-identified patient-level data were extracted from the standard transplant analysis and research file to identify lung offers made by US organ procurement organizations, declined by US lung centers, and transplanted by the University Health Network within the study time frame. We divided the analysis into 2 groups: recipients receiving donor lungs from Canada and recipients receiving donor lungs from the United States. Donor and recipient characteristics between the 2 groups were compared. Primary end point was proportional survival over a 10-year period. Secondary end points included 30-day mortality, intensive care unit and hospital length of stay, severe primary graft dysfunction, and incidence of chronic lung allograft dysfunction.
Results
During the study period, 1424 lung transplants were performed at our center. Of these, 124 (8.7%) were performed using donors from the United States. The incidence of transplants using US donors increased from 5% (5 out of 102) in 2009 to 15% (30 out of 200) in 2018. US donors were younger (aged 41 vs 47 years; P = .004), less likely to be from donors after cardiac death (9.6% vs 20%; P = .008), had higher use of ex vivo lung perfusion (EVLP, 46% vs 27%; P = .0002), and higher incidence of positive nucleic acid test for hepatitis C (16% vs 0.7%; P = .0001). Although the incidence of EVLP utilization was higher in the US lungs versus Canada lungs, more than half of US lungs (54%) proceeded directly to transplantation. Similar short- and long-term outcomes were observed between the 2 groups, including overall survival (hazard ratio, 1.12; 95% CI, 0.85-1.47; P = .40)
Conclusions:
Lung transplantation using donor lungs declined by multiple centers in the United States resulted in similar short- and long-term outcomes compared with donor lungs offered in Canada.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Cypel M, Yeung J, Donahoe L, Yasufuku K, ... Waddell TK, Keshavjee S
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35461711
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Racial disparities in mitral valve surgery: A statewide analysis.

Pienta MJ, Theurer PF, He C, Zehr K, ... Ailawadi G, Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
Objective
Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery.
Methods
All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated.
Results
A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission.
Conclusions
Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Pienta MJ, Theurer PF, He C, Zehr K, ... Ailawadi G, Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35414409
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Pulmonary atresia with intact ventricular septum: Intended strategies.

Sukhavasi A, McHugh-Grant S, Glatz AC, Mondal A, ... Spray TL, Fuller SM
Objective
Neonatal interventional strategies for pulmonary atresia with intact ventricular septum are based on tricuspid valve hypoplasia and right ventricle-dependent coronary circulation. We sought to evaluate long-term outcomes comparing biventricular (BiV) versus single-ventricle (SV) strategies.
Methods
Retrospective review was performed of 119 patients diagnosed with pulmonary atresia with intact ventricular septum from 1995 to 2018. Descriptive statistics summarized patient characteristics and a multivariable Cox survival model was used to compare treatment strategies.
Results
Of 119 patients, 62 (52.1%) were male and 13 (10.9%) had a chromosomal abnormality. BiV was pursued in 53.8% (64 out of 119) and SV in 46.2% (55 out of 119) with median tricuspid valve z scores of -1.59 (interquartile range, -3.03 to 0.21) and -5.12 (interquartile range, -5.60 to -4.06), respectively. The median follow-up was 6 years (interquartile range, 2-15 years). Overall survival at 1, 3, and 10 years was 82.4% (98 out of 119), 80.6% (96 out of 119) and 79.8% (95 out of 119), respectively. End states include 36 (30.3%) BiV, 33 (27.7%) SV, 22 (18.5%) alive without definitive end state, 21 (17.6%) death before end state, 4 (3.4%) 1-and-a-half ventricle, and 3 (2.5%) transplants. No SV were converted to BiV, whereas 4 out of 64 (6.3%) BiV were converted to SV. After adjusting for gender, chromosomal abnormalities, gestational age, and birth weight, SV patients had a significantly higher hazard of mortality (hazard ratio, 9.0; 95% CI, 2.65-30.69; P < .001). Mortality was higher in those with right ventricle-dependent coronary circulation (41.9% [13 out of 31]) compared with those without right ventricle-dependent coronary circulation (7.3% [6 out of 82]) (P < .001).
Conclusions
Pulmonary atresia with intact ventricular septum remains a challenging lesion for those patients on the SV pathway, particularly with right ventricle-dependent coronary circulation.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Sukhavasi A, McHugh-Grant S, Glatz AC, Mondal A, ... Spray TL, Fuller SM
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35414413
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Public reporting for coronary artery bypass graft surgery: The quest for the optimal scorecard.

Ghandour H, Weiss AJ, Gaudino M, Halkos M, ... Roselli EE, Smedira NG
Objective
A number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices.
Methods
Composite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated.
Results
Correlations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = -0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed.
Conclusions
Correlations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center\'s clinical practice and to better inform patients.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Ghandour H, Weiss AJ, Gaudino M, Halkos M, ... Roselli EE, Smedira NG
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35525802
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-term outcomes of primary aortic valve repair for isolated congenital aortic stenosis in children.

Wallace F, Buratto E, Schulz A, d\'Udekem Y, ... Brizard CP, Konstantinov IE
Objective
We aimed to assess the long-term outcomes of children with isolated congenital aortic stenosis who underwent primary aortic valve repair.
Methods
Records of all children (n = 111) with isolated congenital aortic stenosis who underwent primary aortic valve repair between 1980 and 2016 were reviewed. An optimal operative outcome consisted of a residual left ventricular outflow tract peak systolic gradient <35 mm Hg and trivial or less aortic insufficiency.
Results
Median age at surgery was 0.4 years (interquartile range, 1 month-7.9 years) and median weight at surgery was 7.0 kg (interquartile range, 3.7-25.0 kg). Fifty-two patients (46.8%; 52/111) underwent aortic valve repair with the use of patch material. Early mortality was 0.9% (1/111). Late mortality was 0.9% (1/110). Freedom from aortic valve reoperation was 52.1% (95% CI, 38.7-63.8) at 10 years. Freedom from aortic valve replacement was 67.9% (95% CI, 55.4-77.5) at 10 years. An optimal outcome was achieved in 48 patients (43.2%; 48/111). At 10 years, freedom from aortic valve reoperation was 78.2% (95% CI, 63.1-87.8) in patients with an optimal outcome, compared with 39.4% (95% CI, 22.8-55.6) in those with a suboptimal outcome (P = .03). Tricuspid aortic valve was associated with a suboptimal outcome (P = .01).
Conclusions
Aortic valve repair achieves relief of congenital aortic stenosis with very low early mortality and excellent long-term survival, even in neonates. Although nearly half of the patients required aortic valve reoperation by 10 years, two-thirds of the patients remain free from aortic valve replacement. An optimal outcome was more commonly achieved with bicuspid aortic valves compared with tricuspid aortic valves.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Wallace F, Buratto E, Schulz A, d'Udekem Y, ... Brizard CP, Konstantinov IE
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35430079
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Hybrid strategy in neonates with ductal-dependent systemic circulation and multiple risk factors.

Ceneri NM, Desai MH, Tongut A, Ozturk M, ... Yerebakan C, Children\'s National Hospital Hybrid Working Group
Objective
The study objective was to analyze outcomes of the hybrid strategy for ductal-dependent systemic circulation consisting of bilateral pulmonary artery banding with or without ductal stenting followed by delayed Norwood-type palliation or comprehensive stage II operation in high-risk neonates.
Methods
A retrospective analysis was performed between December 2017 and March 2021. Thirty high-risk neonates underwent palliation with bilateral pulmonary artery banding: 11 with prostaglandin therapy and 19 with ductal stenting. Median (range) age and body weight of patients at hybrid stage I were 3 days (0-43) and 2.9 kg (1.1-4.2), respectively. Operative and interstage mortality, morbidity, and reintervention rates were assessed.
Results
Overall survival was 70% (21/30) at a median follow-up time of 9 months (range, 0-37) from hybrid stage I. Operative survival for hybrid stage I was 90% (27/30), of which 2 patients received palliative care, and there was 1 interstage death (4%, 1/27). After hybrid stage I, 37% of patients had a reintervention, and 3% (n = 1) used extracorporeal membrane oxygenation before the next stage of repair. Five patients are awaiting second-stage operation, and 9 patients are awaiting Fontan completion.
Conclusions
High-risk neonates with hypoplastic left heart syndrome or its variants can be successfully palliated using the hybrid strategy and bridged to a delayed Norwood or comprehensive stage II operation with satisfactory survival. This operative approach is a promising alternative pathway for neonates deemed to be high risk due to multiple preoperative risk factors.

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

J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print
Ceneri NM, Desai MH, Tongut A, Ozturk M, ... Yerebakan C, Children's National Hospital Hybrid Working Group
J Thorac Cardiovasc Surg: 16 Mar 2022; epub ahead of print | PMID: 35577592
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

HVAD to HeartMate 3 left ventricular assist device exchange: Best practices recommendations.

Salerno CT, Hayward C, Hall S, Goldstein D, ... Pagani FD, HeartWare HVAD System to HeartMate 3 Left Ventricular Assist System Device Exchange Advisory Group
The HeartWare HVAD System (Medtronic) is a durable implantable left ventricular assist device that has been implanted in approximately 20,000 patients worldwide for bridge to transplant and destination therapy indications. In December 2020, Medtronic issued an Urgent Medical Device Communication informing clinicians of a critical device malfunction in which the HVAD may experience a delay or failure to restart after elective or accidental discontinuation of pump operation. Moreover, evolving retrospective comparative effectiveness studies of patients supported with the HVAD demonstrated a significantly higher risk of stroke and all-cause mortality when compared with a newer generation of a commercially available durable left ventricular assist device. Considering the totality of this new information on HVAD performance and the availability of an alternate commercially available device, Medtronic halted the sale and distribution of the HVAD System in June 2021. The decision to remove the HVAD from commercial distribution now requires the use of the HeartMate 3 left ventricular assist system (Abbott, Inc) if a patient previously implanted with an HVAD requires a pump exchange. The goal of this document is to review important differences in the design of the HVAD and HeartMate 3 that are relevant to the medical management of patients supported with these devices, and to assess the technical aspects of an HVAD-to-HeartMate 3 exchange. This document provides the best available evidence that supports best practices.

Copyright © 2022 The Society of Thoracic Surgeons, The American Association for Thoracic Surgery and European Association for Cardio-Thoracic Surgery. Published by Elsevier Inc. and Oxford. All rights reserved. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 15 Mar 2022; epub ahead of print
Salerno CT, Hayward C, Hall S, Goldstein D, ... Pagani FD, HeartWare HVAD System to HeartMate 3 Left Ventricular Assist System Device Exchange Advisory Group
J Thorac Cardiovasc Surg: 15 Mar 2022; epub ahead of print | PMID: 35341579
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Early posthospitalization recovery after extracorporeal membrane oxygenation in survivors of COVID-19.

Taylor LJ, Jolley SE, Ramani C, Mayer KP, ... Rove JY, ORACLE group
Objective
We sought to determine the influence of venovenous extracorporeal membrane oxygenation (ECMO) on outcomes of mechanically ventilated patients with COVID-19 during the first 120 days after hospital discharge.
Methods
Five academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 admitted during March through May 2020. Survivors had access to a multidisciplinary postintensive care recovery clinic. Physical, psychological, and cognitive deficits were measured using validated instruments and compared based on ECMO status.
Results
Two hundred sixty two mechanically ventilated patients were compared with 46 patients cannulated for venovenous ECMO. Patients receiving ECMO were younger and traveled farther but there was no significant difference in gender, race, or body mass index. ECMO patients were mechanically ventilated for longer durations (median, 26 days [interquartile range, 19.5-41 days] vs 13 days [interquartile range, 7-20 days]) and were more likely to receive inhaled pulmonary vasodilators, neuromuscular blockade, investigational COVID-19 therapies, blood transfusions, and inotropes. Patients receiving ECMO experienced greater bleeding and clotting events (P < .01). However, survival at discharge was similar (69.6% vs 70.6%). Of the 217 survivors, 65.0% had documented follow-up within 120 days. Overall, 95.5% were residing at home, 25.7% had returned to work or usual activity, and 23.1% were still using supplemental oxygen; these rates did not differ significantly based on ECMO status. Rates of physical, psychological, and cognitive deficits were similar.
Conclusions
Our data suggest that COVID-19 survivors experience significant physical, psychological, and cognitive deficits following intensive care unit admission. Despite a more complex critical illness course, longer average duration of mechanical ventilation, and longer average length of stay, patients treated with venovenous ECMO had similar survival at discharge and outcomes within 120 days of discharge.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 14 Mar 2022; epub ahead of print
Taylor LJ, Jolley SE, Ramani C, Mayer KP, ... Rove JY, ORACLE group
J Thorac Cardiovasc Surg: 14 Mar 2022; epub ahead of print | PMID: 35431034
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The Thoracic Surgery Medical Student Association: Understanding the needs of medical students pursuing cardiothoracic surgery in the United States.

Aranda-Michel E, Trager L, Gerhard EF, Magura C, ... Moon M, Sultan I
Objective
Founded in 2020, the Thoracic Surgery Medical Student Association is the first national organization dedicated to supporting medical students interested in pursuing cardiothoracic surgery. Our inaugural survey aimed to describe their basic characteristics and needs.
Methods
An Institutional Review Board-approved, nonincentivized, anonymous electronic survey was distributed to any medical students enrolled in Liaison Committee on Medical Education-accredited medical schools through social media such as Twitter, national organizations (Association of Women Surgeons, Thoracic Surgery Resident Association), and medical school cardiothoracic surgery interest groups. Their basic characteristics, attitudes, and preferences regarding cardiothoracic surgery were recorded.
Results
Of the 167 students from 117 unique schools who completed the survey, 53% identified as White and 57% identified as female. Stages of training were well distributed: 16% first-year medical students, 33% second-year medical students, 16% third-year medical students, 21% fourth-year medical students, and 14% dual degree/research students. Most participants (57%) did not have (32%) or were not aware of having (25%) a thoracic surgery training program at their home institution. The majority (72%) of students reported not having a cardiothoracic surgery interest group at their home institution. The most desired areas of cardiothoracic were networking (31%) and mentorship (28%).
Conclusions
There is a significant need to directly engage medical students who are interested in cardiothoracic surgery considering limited exposure at home institutions through a lack of cardiothoracic surgery interest groups and cardiothoracic residency programs. The Thoracic Surgery Medical Student Association is poised to address these areas with directed networking by connecting cardiothoracic surgery faculty and residents from other institutions with medical students interested in pursuing cardiothoracic surgery.

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

J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print
Aranda-Michel E, Trager L, Gerhard EF, Magura C, ... Moon M, Sultan I
J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print | PMID: 35410691
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Optimal stent length and distal positioning of frozen elephant trunks deployed from the aortic zone 0 for type A acute aortic dissection.

Takagi D, Yamamoto H, Kadohama T, Kiryu K, Wada T, Igarashi I
Objectives
To investigate the optimal stent length and distal positioning of frozen elephant trunks (FETs) in patients with type A acute aortic dissection (TAAD).
Methods
Between October 2014 and April 2021, 191 patients (FET-150 group: 37 patients; stent length, 150 mm; 66.3 ± 12.6 years and FET-non-150 group: 154 patients; 60, 90, or 120 mm; 64.1 ± 12.5 years) underwent total arch repair with FETs for TAAD using the \"zone 0 arch repair\" strategy. In the FET-150 group, the proximal stent end was positioned at the innominate artery origin of the arch. In the FET-non-150 group, the distal stent end was to be positioned just proximal to the aortic valve level using transesophageal echocardiography. The proximal end of the non-stented FET part was sutured to an arch graft together with the aortic wall at 1 to 2 cm proximal to the innominate artery origin.
Results
Distal stent ends were positioned at the thoracic vertebrae (Th) 4-5, 6-7, 8-9, and 10 levels in 0 (0%), 12 (32.4%), 25 (67.6%), and 0 (0%) patients, respectively, in the FET-150 group, and in 6 (3.9%), 98 (63.6%), 49 (31.8%), and 1 (0.7%), respectively, in the FET-non-150 group. No between-group difference in postoperative mortality was noted. The incidence of postoperative residual distal malperfusion and new-onset spinal cord ischemia in the FET-150 versus FET-non-150 groups were 2.7% versus 6.5% (P = .62) and 0% versus 1.9% (P = 1.00), respectively.
Conclusions
FET positioning with the distal stent end at around Th 8 can reduce residual distal malperfusion when a FET with a 150-mm stent is deployed from the aortic zone 0 in patients with TAAD undergoing total arch repair.

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

J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print
Takagi D, Yamamoto H, Kadohama T, Kiryu K, Wada T, Igarashi I
J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print | PMID: 35422323
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Branch pulmonary artery stenosis after arterial switch operation: The effect of preoperative anatomic factors on reintervention.

Luo S, Haranal M, Deng MX, Varenbut J, ... Haller C, Honjo O
Background
We hypothesized that preoperative patient characteristics and branch pulmonary artery (PA) size might influence the rate of postoperative branch PA reintervention in patients with transposition of the great arteries who undergo the arterial switch operation (ASO).
Methods
The retrospective single-center study included 262 consecutive (2008-2017) newborns who underwent the ASO. Demographic characteristics, echocardiography, and clinical outcomes were reviewed. Competing risk analysis modeled incidence of branch PA reintervention and cause-specific hazard regression for predictors analyses.
Results
Median age and weight were 7 (range, 5-11) days and 3.4 (range, 3.1-3.8) kg, respectively. Various types of early branch PA reinterventions (concomitant revision or reintervention during the intensive care unit stay) were required in 28 (10.7%) patients. These patients had prolonged ventilation (P < .001), intensive care unit duration (P < .001), worse right ventricular function (P = .043), and high in-hospital mortality (P = .010). Branch PA dimensions significantly decreased immediately after ASO compared with baseline measurements. The median follow-up duration was 20.8 (range, 0.9-44.7) months. Branch PA reintervention was common among survivors without early reinterventions (9.4%), and even more frequent among those with early reinterventions (25%). Subsequent reintervention (all catheter-based) was necessary for more than one-third of patients after initial branch PA reintervention. The multivariable analysis showed preoperative dimension of the left PA (hazard ratio, 0.527 [95% CI, 0.337-0.823]; P = .005), and right PA (hazard ratio, 0.503 [95% CI, 0.318-0.796]; P = .003) were independently associated with late branch PA reinterventions.
Conclusions
Branch PA reintervention was common and often required surgical or catheter-based reinterventions after ASO. PA branch diameters became significantly smaller after ASO. Smaller preoperative branch PA predicted late branch PA reintervention, indicating a smaller margin of geometrical tolerance to this effect.

Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print
Luo S, Haranal M, Deng MX, Varenbut J, ... Haller C, Honjo O
J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print | PMID: 35437174
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score.

Färber G, Marx J, Scherag A, Saqer I, ... Sponholz C, Doenst T
Objective
Isolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population.
Methods
We calculated STS, European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII), and MELD scores for all of our patients who received isolated tricuspid valve surgery between 2011 and 2020 (n = 157). We determined the MELD score, stratified patients into 3 groups (MELD <10: low, n = 53; 10 to <20: intermediate, n = 78; ≥20: high, n = 26) and describe associated outcomes.
Results
Patients were 72 ± 10 years old and 43% were male. Mean STS score was 4.9 ± 3.5% and ESII was 7.2 ± 6.6%. Mortality was 8.9% at 30 days and 65% at latest follow-up (95% CI, 51%-76%). Median follow-up was 4.4 years (range, 0-9.7 years). Although ESII and STS score accurately predicted 30-day mortality at low MELD scores (observed to expected [O/E] for ESII score = 0.8 and O/E for STS score = 1.0) and intermediate MELD (O/E for ESII score = 0.7, O/E for STS score = 1.0), mortality was underestimated at high MELD (O/E for ESII score = 3.0, O/E for STS score = 4.7). This subgroup also had higher incidence of new-onset hemodialysis. Besides MELD category, recent congestive heart failure, endocarditis, and hemodialysis were also associated with 30-day mortality.
Conclusions
For isolated tricuspid valve regurgitation, classic surgical risk stratification with STS or ESII scores failed to predict perioperative mortality if there was evidence of severe liver dysfunction. Preoperative MELD assessment might be useful to assist in proper risk assessment for isolated tricuspid valve surgery.

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

J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print
Färber G, Marx J, Scherag A, Saqer I, ... Sponholz C, Doenst T
J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print | PMID: 35431033
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-term patient-reported outcomes after non-small cell lung cancer resection.

Heiden BT, Subramanian MP, Liu J, Keith A, ... Puri V, Kozower BD
Objectives
Patient-reported outcomes (PROs) are critical tools for evaluating patients before and after lung cancer resection. In this study, we assessed patient-reported pain, dyspnea, and functional status up to 1 year postoperatively.
Methods
This study included patients who underwent surgery for non-small cell lung cancer at a single institution (2017-2020). We collected PROs using the National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS). Data were prospectively collected and merged with our institutional Society of Thoracic Surgeons data. Using multivariable linear mixed effect models, we compared PROMIS scores for preoperative and several postoperative visits.
Results
From 2017 until 2020, 334 patients underwent lung cancer resection with completed PROMIS assessments. Pain interference, physical function, and dyspnea severity scores were worse 1 month after surgery (P < .001). Pain interference and physical function scores returned to baseline by 6 months after surgery. However, dyspnea severity scores remained persistently worse up to 1 year after surgery (1-month difference, 8.8 ± 1.9; 6-month difference, 3.6 ± 2.2; 1-year difference, 4.9 ± 2.8; P < .001). Patients who received a thoracotomy had worse physical function and pain interference scores 1 month after surgery compared with patients who received a minimally invasive operation; however, there were no differences in PROs by 6 months after surgery.
Conclusions
PROs are important metrics for assessing patients before and after lung cancer resection. Patients may report persistent dyspnea up to 1 year after resection. Additionally, patients undergoing thoracotomy initially report worse pain and physical function but these impairments improve by 6 months after surgery.

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

J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print
Heiden BT, Subramanian MP, Liu J, Keith A, ... Puri V, Kozower BD
J Thorac Cardiovasc Surg: 12 Mar 2022; epub ahead of print | PMID: 35430080
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cannulate, extubate, ambulate approach for extracorporeal membrane oxygenation for COVID-19.

Hayanga JWA, Kakuturu J, Dhamija A, Asad F, ... Sappington P, Badhwar V
Objective
We compared outcomes in patients with severe COVID-19 versus non-COVID-19-related acute respiratory distress syndrome (ARDS) managed using a dynamic, goal-driven approach to venovenous extracorporeal membrane oxygenation (ECMO).
Methods
We performed a retrospective, single-center analysis of our institutional ECMO registry using data from 2017 to 2021. We used Kaplan-Meier plots, Cox proportional hazard models, and propensity score analyses to evaluate the association of COVID-19 status (COVID-19-related ARDS vs non-COVID-19 ARDS) and survival to decannulation, discharge, tracheostomy, and extubation. We also conducted subgroup analyses to compare outcomes with the use of extracorporeal cytoreductive techniques (CytoSorb [CytoSorbents Corp] and plasmapheresis).
Results
The sample comprised 128 patients, 50 with COVID-19 and 78 with non-COVID-19 ARDS. Advancing age was associated with decreased probability of survival to decannulation (P = .04). Compared with the non-COVID-19 ARDS group, patients with COVID-19 had a greater probability of survival to extubation (P < .01) and comparable survival to discharge (P = .14).
Conclusions
Patients with COVID-19 managed with ECMO had comparable outcomes as patients with non-COVID ARDS. A strategy of early extubation and ambulation might be a safe and effective strategy to improve outcomes and survival, even for patients with severe COVID-19.

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

J Thorac Cardiovasc Surg: 11 Mar 2022; epub ahead of print
Hayanga JWA, Kakuturu J, Dhamija A, Asad F, ... Sappington P, Badhwar V
J Thorac Cardiovasc Surg: 11 Mar 2022; epub ahead of print | PMID: 35396123
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Near-infrared fluorescence imaging during ex vivo lung perfusion: Noninvasive real-time evaluation of regional lung perfusion and edema.

Nykänen AI, Mariscal A, Ali A, Hough O, ... Cypel M, Keshavjee S
Objective
Ex vivo lung perfusion (EVLP) is an excellent platform to evaluate donor lung function before transplantation, but novel methods are needed to accurately confirm transplant quality. Near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has been used in various clinical perioperative applications to evaluate tissue perfusion. We used NIRF imaging during pig and human EVLP to evaluate donor lung perfusion and edema.
Methods
Pig lungs with various degrees of lung injury (n = 10) and human lungs rejected from clinical transplantation (n = 3) were imaged during EVLP using intravascular ICG and a SPY Elite (Stryker) NIRF imaging unit. Optimal ICG and imaging conditions, and perfusion and edema quantification methods, were established. Pig lung transplants with extended graft preservation (n = 5) and control native lungs (n = 6) were also imaged.
Results
A single ICG dose resulted in sustained donor lung NIRF throughout the EVLP. Even and homogenous ICG signal was demonstrated in areas of normal lung. Low NIRF was present in regions with poor tissue perfusion, and rapid, intense ICG accumulation occurred in damaged and edematous areas. Segmental perfusion defects were common in the peripheral and elevated regions of the lungs, and serial imaging showed gradual perfusion recovery during EVLP. Impaired microvascular reperfusion, indicated by a decreased NIRF ingress rate, was detected in transplanted pig lungs early after reperfusion.
Conclusions
NIRF imaging enables noninvasive real-time evaluation of lung perfusion and edema during EVLP. Prospective clinical studies are needed to determine the role of NIRF imaging in donor lung assessment and selection, and prediction of posttransplant outcomes.

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

J Thorac Cardiovasc Surg: 11 Mar 2022; epub ahead of print
Nykänen AI, Mariscal A, Ali A, Hough O, ... Cypel M, Keshavjee S
J Thorac Cardiovasc Surg: 11 Mar 2022; epub ahead of print | PMID: 35382935
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Intramuscular stimulation as a new modality to control postthoracotomy pain: A randomized clinical trial.

Moon DH, Park J, Park YG, Kim BJ, ... Lee HS, Lee S
Objective
Postoperative pain after thoracic surgery primarily hinders patients\' mobility, decreasing the quality of life. To date, various modalities have been suggested to improve postoperative pain. However, pain alleviation still remains a challenge, resulting in continued reliance on opioids. To tackle this problem, this study introduces a needle electrical twitch obtaining intramuscular stimulation (NETOIMS) as a new effective treatment modality for postoperative pain after thoracoscopic surgery.
Methods
This randomized clinical trial analyzed patients receiving video-assisted thoracoscopic surgery pulmonary resection between March 2018 and June 2020 at a single institution. A total of 77 patients (NETOIMS, 36; intravenous patient-controlled analgesia, 41) were included. NETOIMS was conducted on the retracted intercostal muscle immediately following the main procedure, just before skin closure. Postoperative pain (numeric rating scale) and oral opioid morphine milligram equivalent were assessed daily until postoperative day 5.
Results
The NETOIMS group had a significantly lower numeric rating scale score on postoperative day (POD) 0 (P < .01), POD2 (P < .001), POD4 (P < .001), and POD5 (P = .01). The predicted time to complete pain resolution was 6.15 days in the NETOIMS group and 20.7 days in the intravenous patient-controlled analgesia group. The oral opioid morphine milligram equivalent was significantly lower in the NETOIMS group on POD0 (P < .001) and POD1 (P < .001).
Conclusions
NETOIMS appears to be an effective modality in alleviating postoperative pain after thoracoscopic surgery, thereby reducing the reliance on opioid use.

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

J Thorac Cardiovasc Surg: 10 Mar 2022; epub ahead of print
Moon DH, Park J, Park YG, Kim BJ, ... Lee HS, Lee S
J Thorac Cardiovasc Surg: 10 Mar 2022; epub ahead of print | PMID: 35410693
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Identification of patient characteristics associated with survival benefit from metformin treatment in patients with stage I non-small cell lung cancer.

Elkin PL, Mullin S, Tetewsky S, Resendez SD, ... Barbi J, Yendamuri S
Background
Non-small cell lung cancer (NSCLC) continues to be a major cause of cancer deaths. Previous investigation has suggested that metformin use can contribute to improved outcomes in NSCLC patients. However, this association is not uniform in all analyzed cohorts, implying that patient characteristics might lead to disparate results. Identification of patient characteristics that affect the association of metformin use with clinical benefit might clarify the drug\'s effect on lung cancer outcomes and lead to more rational design of clinical trials of metformin\'s utility as an intervention. In this study, we examined the association of metformin use with long-term mortality benefit in patients with NSCLC and the possible modulation of this benefit by body mass index (BMI) and smoking status, controlling for other clinical covariates.
Methods
This was a retrospective cohort study in which we analyzed data from the Veterans Affairs (VA) Tumor Registry in the United States. Data from all patients with stage I NSCLC from 2000 to 2016 were extracted from a national database, the Corporate Data Warehouse that captures data from all patients, primarily male, who underwent treatment through the VA health system in the United States. Metformin use was measured according to metformin prescriptions dispensed to patients in the VA health system. The association of metformin use with overall survival (OS) after diagnosis of stage I NSCLC was examined. Patients were further stratified according to BMI and smoking status (previous vs current) to examine the association of metformin use with OS across these strata.
Results
Metformin use was associated with improved survival in patients with stage I NSCLC (average hazard ratio, 0.82; P < .001). An interaction between the effect of metformin use and BMI on OS was observed (χ2 = 3268.42; P < .001) with a greater benefit of metformin use observed in patients as BMI increased. Similarly, an interaction between smoking status and metformin use on OS was also observed (χ2 = 2997.05; P < .001) with a greater benefit of metformin use observed in previous smokers compared with current smokers.
Conclusions
In this large retrospective study, we showed that a survival benefit is enjoyed by users of metformin in a robust stage I NSCLC patient population treated in the VA health system. Metformin use was associated with an 18% improved OS. This association was stronger in patients with a higher BMI and in previous smokers. These observations deserve further mechanistic study and can help rational design of clinical trials with metformin in patients with lung cancer.

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

J Thorac Cardiovasc Surg: 10 Mar 2022; epub ahead of print
Elkin PL, Mullin S, Tetewsky S, Resendez SD, ... Barbi J, Yendamuri S
J Thorac Cardiovasc Surg: 10 Mar 2022; epub ahead of print | PMID: 35469597
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

National trend in failure to rescue after cardiac surgeries.

Alabbadi S, Roach A, Chikwe J, Egorova NN
Objectives
Failure to rescue (FTR), defined as postoperative inpatient death after potentially treatable major complications, is a nationally endorsed quality of care measure, however, the effect of practice change on FTR is unknown. In this study, we aimed to define the FTR trend after cardiac surgery in the United States.
Methods
In this retrospective analysis of the National Inpatient Sample database we identified adult patients who underwent cardiac surgeries in the United States between 2000 and 2018, defined incidence and trends in FTR adjusted for sex, age, diagnosis-related group, and comorbidity. Trends were analyzed using Joinpoint (Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute) regression software.
Results
The study included 6,185,032 hospitalizations for cardiac surgeries. Risk-adjusted FTR after deep venous thromboembolism/pulmonary embolism and sepsis has declined from 2000 to 2018 (annual percent change [APC] = -6.4% and -11.6%, respectively; P < .001). After pneumonia, FTR has increased significantly since 2011 (APC = 9.3%; P < .001). Since 2012, FTR due to gastrointestinal hemorrhage has increased substantially (APC = 15.9%; P < .001). The risk-adjusted FTR rate in patients 75 years of age or older significantly declined until 2011 (APC = -12.6%; P < .001) and became comparable with the FTR rate of younger patients by the end of the study.
Conclusions
There have been significant reductions in FTR in elderly patients and a reduction in postprocedural mortality associated with sepsis and venous thromboembolism overall after cardiac surgery. This might provide evidence supporting national targeted quality metrics and care bundles for complications such as pneumonia and gastrointestinal bleeding, which had an increasing FTR.

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

J Thorac Cardiovasc Surg: 04 Mar 2022; epub ahead of print
Alabbadi S, Roach A, Chikwe J, Egorova NN
J Thorac Cardiovasc Surg: 04 Mar 2022; epub ahead of print | PMID: 35346488
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Risk score for arch reconstruction under circulatory arrest with hypothermia: The ARCH score.

Guo MH, Stevens LM, Chu MWA, Hage A, ... Boodhwani M, Canadian Thoracic Aortic Collaborative (CTAC)
Objective
Currently, there is no risk scores built to predict risk in thoracic aortic surgery. This study aims to develop and internally validate a risk prediction score for patients who require arch reconstruction with hypothermic circulatory arrest.
Methods
From 2002 to 2018, data for 2270 patients who underwent aortic arch surgery in 12 institutions in Canada were retrospectively collected. The outcomes modeled included in-hospital mortality and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity. Multivariable logistic regression using least absolute shrinkage and selection operator selection method and mixed-effect regression model was used to select the predictors. Internal calibration of the final models is presented with an observed-versus-predicted plot.
Results
There were 182 in-hospital deaths (8.0%), and the incidence of Society of Thoracic Surgeons-defined composite for mortality or major morbidity was 27.9%. Variables that increased risk of mortality are age, chronic obstructive pulmonary disease, atrial fibrillation, peripheral vascular disease, New York Heart Association class ≥III symptoms, acute aortic dissection or rupture, use of elephant trunk, concomitant surgery, and increased cardiopulmonary bypass time, with median c-statistics of 0.85 on internal validation. The c-statistics was 0.77 for the model predicting Society of Thoracic Surgeons-defined composite. Internal assessment shows good overall calibration for both models.
Conclusions
We developed and internally validated a risk score for patients undergoing arch surgery requiring hypothermic circulatory arrest using a multicenter database. Once externally validated, the ARCH (Arch Reconstruction under Circulatory arrest with Hypothermia) score would allow for better patient risk-stratification and aid in the decision-making process for surgeons and patient prior to surgery.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 03 Mar 2022; epub ahead of print
Guo MH, Stevens LM, Chu MWA, Hage A, ... Boodhwani M, Canadian Thoracic Aortic Collaborative (CTAC)
J Thorac Cardiovasc Surg: 03 Mar 2022; epub ahead of print | PMID: 35382936
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

A novel intrapericardial pulsatile device for individualized, biventricular circulatory support without direct blood contact.

Schueler S, Bowles CT, Hinkel R, Wohlfarth R, ... Smail H, de Vaal MH
Objective
Due to severely limited donor heart availability, durable mechanical circulatory support remains the only treatment option for many patients with end-stage heart failure. However, treatment complexity persists due to its univentricular support modality and continuous contact with blood. We investigated the function and safety of reBEAT (AdjuCor GmbH), a novel, minimal invasive mechanical circulatory support device that completely avoids blood contact and provides pulsatile, biventricular support.
Methods
For each animal tested, an accurately sized cardiac implant was manufactured from computed tomography scan analyses. The implant consists of a cardiac sleeve with three inflatable cushions, 6 epicardial electrodes and driveline connecting to an electro-pneumatic, extracorporeal portable driver. Continuous epicardial electrocardiogram signal analysis allows for systolic and diastolic synchronization of biventricular mechanical support. In 7 pigs (weight, 50-80 kg), data were analyzed acutely (under beta-blockade, n = 5) and in a 30-day long-term survival model (n = 2). Acquisition of intracardiac pressures and aortic and pulmonary flow data were used to determine left ventricle and right ventricle stroke work and stroke volume, respectively.
Results
Each implant was successfully positioned around the ventricles. Automatic algorithm electrocardiogram signal annotations resulted in precise, real-time mechanical support synchronization with each cardiac cycle. Consequently, progressive improvements in cardiac hemodynamic parameters in acute animals were achieved. Long-term survival demonstrated safe device integration, and clear and stable electrocardiogram signal detection over time.
Conclusions
The present study demonstrates biventricular cardiac support with reBEAT. Various demonstrated features are essential for realistic translation into the clinical setting, including safe implantation, anatomical fit, safe device-tissue integration, and real-time electrocardiogram synchronized mechanical support, result in effective device function and long-term safety.

Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print
Schueler S, Bowles CT, Hinkel R, Wohlfarth R, ... Smail H, de Vaal MH
J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print | PMID: 35379474
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Patterns and influence of nodal metastases after neoadjuvant chemoradiation and R0 resection in esophageal adenocarcinoma.

Harrington CA, Carr RA, Hsu M, Tan KS, ... Jones DR, Molena D
Objective
Little is known about the pattern of nodal metastases in patients with esophageal adenocarcinoma who have received neoadjuvant chemoradiation and undergone surgery. We sought to assess this pattern and evaluate its association with prognosis.
Methods
All patients with esophageal adenocarcinoma who underwent neoadjuvant chemoradiation and R0 esophagectomy between 2010 and 2018 at our institution were included (n = 537). The primary objective was to evaluate the association of sites of lymph node metastases with disease-free survival. The number of nodal stations and individual sites of nodal metastases were evaluated first in univariable then in separate multivariable Cox regression models adjusted for clinical factors.
Results
Of 537 patients, 193 (36%) had pathologic nodal metastases at the time of surgery; 153 (28%) had single-station disease, 32 (6.0%) had 2-station disease, and 8 (1.5%) had 3-station disease. The majority of patients with multiple positive nodal stations had positive nodes in the paraesophageal (93%) and/or left gastric stations (60%). Multivariable models controlling for clinical factors showed that an increasing number of positive nodal stations (hazard ratio, 1.59; 95% CI, 1.35-1.84; P < .01)-in particular, the subcarinal (hazard ratio, 2.78; 95% CI, 1.54-5.03; P < .01) and paraesophageal stations (hazard ratio, 2.0; 95% CI, 1.58-2.54; P < .01)-was associated with increased risk of recurrence.
Conclusions
One-third of patients who have undergone R0 resection for esophageal adenocarcinoma following induction chemoradiation therapy have metastatic lymph nodes. An increasing number of nodal stations, particularly paraesophageal and subcarinal metastases, were associated with increased risk of recurrence.

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

J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print
Harrington CA, Carr RA, Hsu M, Tan KS, ... Jones DR, Molena D
J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print | PMID: 35346491
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Safety of lung cancer surgery during COVID-19 in a pandemic epicenter.

Villena-Vargas J, Lutton EM, Mynard N, Nasar A, ... Port JL, Altorki NK
Background
The influence of SARS-CoV-2 on surgery for non-small cell lung cancer needs to be understood to inform clinical decision making during and after the COVID-19 pandemic.
Objective
This study reports on the 90-day rate of infection as well as the morbidity and mortality of lung surgery for cancer in a tertiary care hospital located in a pandemic epicenter.
Methods
We conducted a retrospective review of a prospective database to identify consecutive patients who underwent lung cancer resection before (January 1, 2020-March 10, 2020, group 1; 57 patients) and during the COVID-19 pandemic (March 11, 2020-June 10, 2020, group 2; 41 patients). The primary end point was the occurrence of SARS-CoV-2 infection during the first 90-days after surgery. The secondary outcome measure was 90-day perioperative morbidity and mortality.
Results
Patient characteristics were not significantly different between the groups. Ninety-day COVID-19 infection rates was 7.3% (3 out of 41) for patients undergoing an operation during the pandemic and 3.5% (2 out of 57) in patients operated on immediately before the pandemic. All patients tested positive 10 to 62 days after the index surgical procedure following hospital discharge. Four COVID-19-positive patients were symptomatic and 4 out of 5 patients required hospitalization, were men, previous or current smokers with hyperlipidemia, and underwent a sublobar resection. Univariate analysis did not identify any differences in postoperative complications before or during the COVID-19 pandemic. Ninety-day mortality was 5% (2 out of 41) for lung cancer surgery performed during the pandemic, with all deaths occurring due to COVID-19, compared with 0% (0 out of 57) mortality in patients who underwent an operation before the pandemic.
Conclusions
During the COVID-19 pandemic, COVID-19 infections occurred in 7.3% of patients who underwent surgery for non-small cell lung cancer. In this series all infections occurred after hospital discharge. Our results suggest that COVID-19 infections occurring within 90 days of surgery portend a 40% mortality, warranting close postoperative surveillance.

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

J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print
Villena-Vargas J, Lutton EM, Mynard N, Nasar A, ... Port JL, Altorki NK
J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print | PMID: 35459540
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Outcome after pulmonary endarterectomy for segmental chronic thromboembolic pulmonary hypertension.

de Perrot M, Donahoe L, McRae K, Thenganatt J, ... Granton J, Canadian CTEPH Working Group
Objective
Determine the long-term outcome and need for additional therapy after pulmonary endarterectomy (PEA) for segmental chronic thromboembolic pulmonary hypertension.
Methods
Retrospective analysis of a prospective cohort of 401 consecutive Canadian patients undergoing PEA between August 2005 and March 2020 in Toronto. The outcome of segmental disease defined as Jamieson type 3 was compared with more proximal disease defined as Jamieson type 1 and 2. The cohort was divided into 3 intervals to analyze the trend over time: 2005-2010, 2011-2015, and 2016-2020.
Results
Type 3 disease accounted for 41% of patients undergoing PEA durig 2016-2020 compared with 7% in 2006-2010. Total pulmonary vascular resistance improved by 505 ± 485 dynes/s/cm-5 in type 3 disease and by 593 ± 452 dynes/s/cm-5 in type 1 or 2 disease (P = .07). Mortality after PEA was similar between type 3 and type 1 and 2 disease at 30-days (2.8% vs 2.3%; P = .8) and at 1 year (7.7% vs 5.5%; P = .4). At 5 years, the survival was lower in type 3 disease (80% vs 91% in type 1 or 2 disease; P = .002). Type 3 disease was an independent predictor for the initiation of pulmonary hypertension-targeted medical therapy after PEA with a cumulative incidence of 38% at 10 years compared with 20% in type 1 and 2 disease (P < .0001). Post-PEA balloon pulmonary angioplasty was predominantly performed in type 3 disease (8% vs 1% in more type 1 or 2 disease; P = .0002).
Conclusions
PEA achieved excellent early and long-term results in segmental chronic thromboembolic pulmonary hypertension. However, patients with segmental disease are at increased risk of requiring additional therapy after PEA and should be carefully monitored.

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

J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print
de Perrot M, Donahoe L, McRae K, Thenganatt J, ... Granton J, Canadian CTEPH Working Group
J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print | PMID: 35361492
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Heart-kidney listing is better than isolated heart listing for pediatric heart transplant candidates with significant renal insufficiency.

Dani A, Price N, Thangappan K, Ryan TD, ... Zafar F, Morales DLS
Objectives
Significant renal insufficiency is identified as a risk factor for post-transplantation mortality in pediatric heart transplant recipients. This study evaluates simultaneous heart-kidney transplantation listing outcomes compared with heart transplant for pediatric candidates with significant renal insufficiency.
Methods
The United Network for Organ Sharing registry was searched for patients (January 1987 to March 2020) who were simultaneously listed for a heart-kidney transplantation or for heart transplant with significant renal insufficiency at the time of listing. Significant renal insufficiency was defined as needing dialysis or having a low estimated glomerular filtration rate (<40 mL/min). Survival was calculated using Kaplan-Meier analysis.
Results
A total of 427 cases were identified; 109 were listed for heart-kidney transplantation, and 318 were listed for heart transplant alone. Median time on the waitlist was 101 days (interquartile range, 28-238) for heart-kidney transplantation listings compared with 39 days (14-86) and 23.5 days (6-51) for heart transplant recipients with a low estimated glomerular filtration rate (P = .002) or on dialysis (P < .001), respectively. Of all heart-kidney transplantation listings, 66% (n = 71) received a transplant compared with 54% (n = 173) of heart transplantation with significant renal insufficiency (P = .005) with a mean survival of 14.6 years (12.7-16.4 years) for heart transplant without significant renal insufficiency at transplantation and 7.6 years (5.4-9.9 years) for heart transplant with significant renal insufficiency at transplantation. At 1 year after listing, 69% of heart-kidney transplantation listed recipients were alive, compared with 51% of heart transplant listed recipients (P = .029). Heart-kidney transplantation recipients had better 1-year post-transplantation survival (86%) than heart transplantation with significant renal insufficiency at transplant (66%) (P = .001). There was no significant difference in the 1- and 5-year survivals of those undergoing heart transplantation listed with significant renal insufficiency but no significant renal insufficiency at the time of transplant (89% and 78%) and heart-kidney transplantation recipients (86% and 81%; P = .436).
Conclusions
Pediatric candidates with significant renal insufficiency listed for heart-kidney transplantation have superior waitlist and post-transplantation outcomes compared with those listed for heart transplant alone. Patients with significant renal insufficiency should be listed for heart-kidney transplantation, however; if their renal function improves significantly, heart transplant alone appears judicious.

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

J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print
Dani A, Price N, Thangappan K, Ryan TD, ... Zafar F, Morales DLS
J Thorac Cardiovasc Surg: 01 Mar 2022; epub ahead of print | PMID: 35331555
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Repair of complete atrioventricular septal defect between 2 and 3.5 kilograms: Defining the limits of safe repair.

Goutallier CS, Buratto E, Schulz A, Hu T, ... Konstantinov IE, Brizard CP
Objectives
Repair of complete atrioventricular septal defect (cAVSD) is routinely performed at around 3 months of age with good results. However, some patients require earlier surgery due to heart failure or failure to thrive. It is uncertain whether cAVSD repair performed on patients ≤3.5 kg leads to increased mortality and reoperation on the left atrioventricular valve.
Methods
All patients who underwent cAVSD repair from 1990 to 2019 at a single institution were included in the study. Data were obtained from retrospective review of medical records and correspondence with cardiologists.
Results
Of 456 patients, 12.9% (59/456) weighed ≤3.5 kg at time of repair. This group was younger (P < .01) and had greater rates of heart failure (P < .01) and failure to thrive (P = .02). There was no significant difference in early mortality between the 2 groups (1.7% [1/59] vs 3.0% [12/397], P = 1.0). Survival at 20 years was 83.8% in those ≤3.5 kg, compared with 90.4% in those >3.5 kg, with no significant difference between the 2 groups (P = .68). Freedom from left atrioventricular valve reoperation at 20 years was 73.6% in those ≤3.5 kg, compared with 74.5% in those >3.5 kg, with no significant difference between the 2 groups (P = .45).
Conclusions
Repair of cAVSD in children ≤3.5 kg appears to be safe, with similar overall survival and freedom from reoperation compared with those >3.5 kg. These findings add further support to an approach of early complete repair in children with severe heart failure or failure to thrive.

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

J Thorac Cardiovasc Surg: 25 Feb 2022; epub ahead of print
Goutallier CS, Buratto E, Schulz A, Hu T, ... Konstantinov IE, Brizard CP
J Thorac Cardiovasc Surg: 25 Feb 2022; epub ahead of print | PMID: 35341580
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Comparing the patency of the left internal mammary in single, sequential, and y grafts.

Singh B, Singh G, Tripathy A, Larobina M, Goldblatt J, Tatoulis J
Background
To maximize arterial grafts, left internal mammary (LIMA) sequential and y grafts are used. The aim is to compare the angiographic patency of the LIMA in these configurations.
Methods
Between 2002 and 2020, angiography was performed on 1000 patients who either had a single (570), sequential (100), or LIMA y (129) graft. The LIMA was divided into segments (S); S1: LIMA inflow to the first anastomosis, S2: terminal portion of the LIMA to left anterior descending (LAD), and S3; the y-limb anastomosis to a coronary. S1 and S2 patency analysis was carried out with logistic regression.
Results
Failure of the S1 and S2 was 3.7% single, 9% sequential, and 6.2 y graft (P = .049). Segment 1 failed in 3.7% in single, 5% in sequential, and 0.8% in y grafts (P = .049). Segment 3 failure was 10.3%. Regression revealed female sex and sequential grafts were associated with decreased S1 and S2 patency.
Conclusions
Single grafts have the best patency. Failure in sequential grafts leads to increased occlusion of the LIMA inflow, whereas y-graft failure tends to occlude the y limb. When arterial conduit is sparse, a y graft should be considered.

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

J Thorac Cardiovasc Surg: 24 Feb 2022; epub ahead of print
Singh B, Singh G, Tripathy A, Larobina M, Goldblatt J, Tatoulis J
J Thorac Cardiovasc Surg: 24 Feb 2022; epub ahead of print | PMID: 35317917
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Transfusion of non-red blood cell blood products does not reduce survival following cardiac surgery.

Bianco V, Aranda-Michel E, Serna-Gallegos D, Dunn-Lewis C, ... Navid F, Sultan I
Objectives
The literature supports the assertion that patients undergoing cardiac surgery who receive perioperative packed red blood cell (pRBC) transfusions have increased associated mortality. The aim of the current study is to assess whether there is an association between non-pRBC blood product transfusions and increased mortality.
Methods
Data from our center\'s Society of Thoracic Surgeons database included patients who underwent cardiac surgery from 2010 to 2018. Patients with pRBC transfusions or circulatory arrest were excluded. Propensity matching was performed (1:1; caliper = 0.2 times the standard deviation of logit of propensity score). Kaplan-Meier estimates and Cox regression were used. Cardiac transplant, ventricular assist devices, transcatheter aortic valves, and patients who had experienced circulatory arrest were excluded from this analysis.
Results
A total of 8042 patients met criteria for analysis. Following propensity matching (1:1), 395 patients requiring perioperative non-pRBC blood products (platelets, fresh-frozen plasma, and cryoprecipitate) were matched with 395 nontransfusion patients, yielding equitable patient cohorts. Median follow-up was 4.5 (3.0-6.4) years. Patients received platelets (327 [82.8%]), fresh-frozen plasma (141 [35.7%]), and cryoprecipitate (60 [15.2%]). There was no significant difference in the postoperative mortality (6 [1.5%] vs 4 [1.0%]; P = .52). Reoperation (20 [5.0%] vs 8 [2.0%]; P < .02) and prolonged ventilation (36 [9.1%] vs 19 [4.8%]; P < .02) were greater in the transfusion group. Emergent operation (odds ratio [OR] 2.86 [1.72-4.78]; P < .001), intra-aortic balloon pump (OR 3.24 [1.64-6.39]; P < .001), and multivalve operation (OR 4.34 [2.83-6.67]; P < .001) were significantly associated with blood product use. Blood product transfusion (hazard ratio; 1.15 [0.89-1.48]; P = .3) was not significantly associated with increased mortality risk. There was no significant long-term survival difference between cohorts.
Conclusions
Patients who undergo cardiac surgery requiring blood products alone, without pRBC transfusion, have similar postoperative and long-term survival compared with patients not requiring blood products. These data are based on a limited patient sample, and future studies will aid in improving the generalizability of these results.

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

J Thorac Cardiovasc Surg: 24 Feb 2022; epub ahead of print
Bianco V, Aranda-Michel E, Serna-Gallegos D, Dunn-Lewis C, ... Navid F, Sultan I
J Thorac Cardiovasc Surg: 24 Feb 2022; epub ahead of print | PMID: 35337681
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

The Clinical SYNTAX score predicts survival better than the SYNTAX score in coronary revascularization.

Barac YD, Witberg G, Assali A, Klempfner R, ... Kornowski R, Aravot D
Background
The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial showed that the SYNTAX score (SS) is a useful tool for customizing revascularization treatment for patients with multivessel coronary disease. In the past decade, the Clinical SS (CSS) has emerged as a comprehensive tool. This novel tool considers the SS as well as patient clinical parameters such as age, creatinine clearance, and ejection fraction, which were shown to be relevant for patient prognosis. Thus, in the current work we set out to compare the survival predictive values of the SS versus the CSS and their future application in real-world implementation of the revascularization guidelines.
Methods
This study was a subanalysis of data collected in a prospective national registry in Israel that enrolled consecutive patients with left main and/or 2- to 3-vessel coronary artery disease involving the proximal or mid-left anterior descending artery; the MULTI-vessel Coronary Artery Disease (MULTICAD). The revascularization method was chosen by the physicians taking care of the patients at each hospital and the patients were followed for 5 years. Patients were categorized according to their SS, the CSS, and their revascularization method (primary coronary intervention [PCI] vs coronary artery bypass grafting [CABG]) and patient survival were compared.
Results
A total of 585 patients were enrolled in the study and were followed for 5 years. The median CSS was 27, with 288 patients showing a CSS ≥27, with a mean CSS of 47.85 and a mean SS of 29.05. At 3 and 5 years post-treatment, the CSS ≥27 group had a lower survival probability, CSS ≥27 was associated with a lower survival probability among patients who underwent PCI compared with those who underwent CABG. More specifically, the high-CSS CABG group had a 5-year mortality rate of 16.8%, whereas the high-CSS PCI group had a 5-year mortality rate of 32.2%. In a comparison of SS with CSS for the 5-year mortality outcome prediction, CSS was superior to SS with a higher area under the curve.
Conclusions
This prospective registry of real-world revascularization strategies in patients with multivessel disease showed that CSS is a better predictive tool of postrevascularization survival than SS. Moreover, it showed that surgical revascularization in patients with CSS ≥27 is associated with better all-cause mortality outcome after CABG as compared with after PCI. This attests to the need for a score that considers clinical parameters in a real-world scenario.

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

J Thorac Cardiovasc Surg: 24 Feb 2022; epub ahead of print
Barac YD, Witberg G, Assali A, Klempfner R, ... Kornowski R, Aravot D
J Thorac Cardiovasc Surg: 24 Feb 2022; epub ahead of print | PMID: 35331554
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.