Journal: J Thorac Cardiovasc Surg

Sorted by: date / impact
Abstract

The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation.

Tanaka Y, Nakajima T, Fischer I, Wan F, ... Masood MF, Itoh A
Objective
The study objective was to investigate the progression of uncorrected mild aortic insufficiency and its impact on survival and functional status after left ventricular assist device implantation.
Methods
We retrospectively reviewed 694 consecutive patients who underwent implantation of a continuous-flow left ventricular assist device between January 2006 and March 2018. Pre-left ventricular assist device transthoracic echocardiography identified 111 patients with mild aortic insufficiency and 493 patients with trace or no aortic insufficiency. To adjust for differences in preoperative factors, propensity score matching was used, resulting in 101 matched patients in each of the mild aortic insufficiency and no aortic insufficiency groups.
Results
Although both groups showed similar survival (P = .58), the mild aortic insufficiency group experienced higher incidence of readmission caused by heart failure (hazard ratio, 2.62; 95% confidence interval, 1.42-4.69; P < .01). By using the mixed effect model, pre-left ventricular assist device mild aortic insufficiency was a significant risk factor for both moderate or greater aortic insufficiency and worsening New York Heart Association functional status (P < .01).
Conclusions
Patients with uncorrected mild aortic insufficiency had a higher risk of progression to moderate or greater aortic insufficiency after left ventricular assist device implantation with worse functional status and higher incidence of readmission caused by heart failure compared with patients without aortic insufficiency. Further investigations into the safety and efficacy of concomitant aortic valve procedures for mild aortic insufficiency at the time of left ventricular assist device implant are warranted to improve patients\' quality of life, considering the longer left ventricular assist device use as destination therapy and bridge to transplant with the new US heart allocation system.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Nov 2020; 160:1490-1500.e3
Tanaka Y, Nakajima T, Fischer I, Wan F, ... Masood MF, Itoh A
J Thorac Cardiovasc Surg: 29 Nov 2020; 160:1490-1500.e3 | PMID: 32998831
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Abstract

Influence of broader geographic allograft sharing on outcomes and cost in smaller lung transplant centers.

Haywood N, Mehaffey JH, Kilbourne S, Mannem H, ... Krupnick AS, Agarwal A
Objective
On November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation.
Methods
Patients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras.
Results
Similar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%; P < .001), increased travel distance (145 vs 235 miles; P = .004), travel cost ($8626 vs $14,482; P < .001), and total procurement cost ($60,852 vs $69,052; P = .001) were observed postimplementation. We also document an increase in waitlist mortality postimplementation (6.9 vs 31.6 per 100 patient-years; P < .001).
Conclusions
Following implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged, including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 05 Sep 2020; epub ahead of print
Haywood N, Mehaffey JH, Kilbourne S, Mannem H, ... Krupnick AS, Agarwal A
J Thorac Cardiovasc Surg: 05 Sep 2020; epub ahead of print | PMID: 33008575
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Abstract

A progress report on reimplantation of the aortic valve.

David TE, David CM, Ouzounian M, Feindel CM, Lafreniere-Roula M
Objective
To examine the late outcomes of reimplantation of the aortic valve (RAV) in patients followed prospectively since surgery.
Methods
All 465 patients who had RAV from 1989 to 2018 were followed prospectively with periodic clinical and echocardiographic assessments. Mean follow-up was 10 ± 6 years and 98% complete.
Results
Patients\' mean age was 47 ± 5.1 years, and 78% were men. The aortic root aneurysm was associated with Marfan syndrome in 164 patients, Loeys-Dietz syndrome in 13, bicuspid aortic valve (BAV) in 67, and type A aortic dissection in 33. Aortic insufficiency (AI) was greater than mild in 298 patients. Concomitant procedures were performed in 105 patients. There were 5 operative and 51 late deaths. At 20 years, 69.1% of patients were alive and free from aortic valve reoperation, and the cumulative probability of aortic valve reoperation with death as a competing risk was 6.0%, and the cumulative probability of developing moderate or severe AI was 10.2%. Only time per 1-year interval was associated with the development of postoperative AI by multivariable analysis (hazard ratio, 1.06; 95% confidence interval, >1.02-1.10; P = .006). Gradients across preserved BAV increased in 5 patients, and 1 required reoperation for aortic stenosis. Distal aortic dissections occurred in 22 patients, primarily in those with associated genetic syndromes.
Conclusions
RAV provides excellent long-term results, but there is a progressive rate of AI over time, and patients with BAV may develop aortic stenosis. Patients with genetic syndromes have a risk of distal aortic dissections. Continued surveillance after RAV is necessary.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2020; epub ahead of print
David TE, David CM, Ouzounian M, Feindel CM, Lafreniere-Roula M
J Thorac Cardiovasc Surg: 04 Sep 2020; epub ahead of print | PMID: 33008570
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Abstract

Esophageal adenocarcinoma with any component of signet ring cells portends poor prognosis and response to neoadjuvant therapy.

Corsini EM, Foo WC, Mitchell KG, Zhou N, ... Vaporciyan AA, Walsh GL
Background
Multiple investigations have shown inferior outcomes for esophageal cancer patients with signet ring cell (SRC) histology. Traditionally, SRC adenocarcinoma has been defined by ≥50% of the tumor composed of SRC. We hypothesized that patients with SRC even <50% would show resistance to standard multimodality therapy with poorer long-term outcomes.
Methods
Patients treated with trimodality therapy for adenocarcinoma from 2006 to 2018 were evaluated for SRC on pretreatment biopsy specimens. Available hematoxylin and eosin slides containing SRC tumors were re-reviewed by an esophageal pathologist to quantify the percent composition of SRC.
Results
SRC histology was identified on at least 1 pathologic specimen in 106 of 819 (13%) patients. Rates of pathologic complete response (pCR) among usual-type and SRC tumors were 25% (177/713) and 10% (11/106), respectively (P = .006). The pretreatment SRC components did not independently affect the rate of pCR (1%-10% SRC: 4% [2/46] pCR; 11%-49% SRC: 25% [7/28] pCR; 50%-100% SRC: 7% [2/30] pCR). Kaplan-Meier analysis demonstrated worse survival among patients with any degree of SRC present on pretreatment biopsy, as compared with usual-type esophageal adenocarcinoma (P < .0001). Cox multivariable analysis failed to identify a relationship between increasing SRC component and poorer survival.
Conclusions
We present the only known evaluation of the percentage of SRC component in esophageal carcinoma. Our data support the hypothesis that esophageal adenocarcinoma with any component of SRC are more resistant to chemoradiation with poorer survival. Pathologic reporting of esophageal adenocarcinoma should include any component of SRC. Alternative therapies in patients with any SRC component may be indicated.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Sep 2020; epub ahead of print
Corsini EM, Foo WC, Mitchell KG, Zhou N, ... Vaporciyan AA, Walsh GL
J Thorac Cardiovasc Surg: 04 Sep 2020; epub ahead of print | PMID: 33010880
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Abstract

Surgery and invasive diagnostic procedures for benign disease are rare in a large low-dose computed tomography lung cancer screening program.

Ho H, Williamson C, Regis SM, Stock CT, ... McKee AB, Servais EL
Objective
Lung cancer screening with low-dose chest computed tomography improves survival. However, concerns about overdiagnosis and unnecessary interventions persist. We reviewed our lung cancer screening program to determine the rate of surgery and invasive procedures for nonmalignant disease.
Methods
We reviewed all patients undergoing lung cancer screening from January 2012 to June 2017 with follow-up through January 2019. Patients with suspicious findings (Lung CT Screening Reporting and Data System 4) were referred for further evaluation.
Results
Of 3280 patients screened, 345 (10.5%) had Lung CT Screening Reporting and Data System 4 findings. A total of 311 patients had complete follow-up, of whom 93 (29.9%) were diagnosed with lung cancer. Eighty-three patients underwent lung surgery (2.5% of screened patients). Forty patients underwent lobectomy (48.2%), 3 patients (3.6%) underwent bilobectomy, and 40 patients (48.2%) underwent sublobar resection. Fourteen patients underwent surgery for benign disease (0.43% of screened patients). Fifty-four patients, 5 with benign disease, had at least 1 invasive diagnostic procedure but never underwent surgery. The incidence of any invasive intervention for nonmalignant disease was 0.95% (31/3280 patients). There were no postprocedural deaths within 60 days. Twenty-five patients (0.76%) underwent stereotactic body radiation therapy; 19 patients (76%) had presumed lung cancer without pretreatment pathologic confirmation.
Conclusions
Surgical resection for benign disease occurred in 0.43% of patients undergoing lung cancer screening. The combined incidence of any invasive diagnostic or therapeutic intervention, including surgical resection, for benign disease was only 0.95%. Periprocedural complications were rare. These results indicate that concern over unnecessary interventions is overstated and should not hinder adoption of lung cancer screening. A multidisciplinary team approach, including thoracic surgeons, is critical to maintain an appropriate rate of interventions in lung cancer screening.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 07 Sep 2020; epub ahead of print
Ho H, Williamson C, Regis SM, Stock CT, ... McKee AB, Servais EL
J Thorac Cardiovasc Surg: 07 Sep 2020; epub ahead of print | PMID: 33023746
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Abstract

Scavenging right atrial Bretschneider histidine-tryptophan-ketoglutarate cardioplegia: Impact on hyponatremia and seizures in pediatric cardiac surgery patients.

Turner II, Ruzmetov M, Niu J, Bibevski S, Scholl FG
Objective
Custodiol-HTK cardioplegia (Custodiol-HTK Koheler Chemie, GmbH, Bensheim, Germany) causes fluctuations in serum sodium levels, hyponatremia, and is associated with postoperative seizures. We investigated the influence of scavenging right atrial effluent during delivery on intraoperative serum sodium levels and postoperative seizure incidence in pediatric cardiac surgery patients.
Methods
A total of 204 patients younger than age 18 years undergoing congenital heart surgery between January 2016 and March 2018 were analyzed retrospectively. Serum sodium levels after administration of Custodiol-HTK cardioplegia were compared between the scavenge and nonscavenge groups and then in the propensity score-matched cohort (n = 96). Postoperative seizures were documented clinically and with electroencephalogram findings. Logistic regression models were used to identify the independent predictors of serum sodium level after aortic crossclamp.
Results
Of 204 patients, 156 (76.5%) were in the nonscavenge, and 48 (23.5%) in the scavenge groups. A serum sodium level <130 mEq/L after crossclamp and administration of Custodiol-HTK cardioplegia in the nonscavenge group were 70% versus 21% in the scavenge group (odds ratio, 8.8; 95% confidence interval, 4.1-18.3; P < .0001) in the entire cohort, and 77% versus 21% (odds ratio, 12.8; 95% confidence interval, 4.8-33.1; P < .0001) in the propensity score-matched cohort. Of 16 patients experiencing a postoperative seizure, 14 (87.5%) had a sodium level <130 mEq/L and 2 (12.5%) had a sodium level ≥130 mEq/L (odds ratio, 5.1; 95% confidence interval, 1.3-22.8; P = .021) after crossclamp. Postoperative seizures occurred in the nonscavenge group but not the scavenge group in the entire cohort (P = .02) and in the propensity score-matched patients (P = .041). Multivariable analysis of the entire cohort showed that scavenge intervention was an independent factor associated with significantly decreased risk of sodium level <130 mEq/L (odds ratio, 0.17; 95% confidence interval, 0.08-0.36; P = .000).
Conclusions
Right atrial effluent scavenging was protective against fluctuations in serum sodium levels after crossclamp and Custodiol-HTK cardioplegia administration independently in both entire and matched cohort, and was also associated with decreased incidence of postoperative seizures.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 03 Sep 2020; epub ahead of print
Turner II, Ruzmetov M, Niu J, Bibevski S, Scholl FG
J Thorac Cardiovasc Surg: 03 Sep 2020; epub ahead of print | PMID: 33036746
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Abstract

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients.

Lorusso R, Whitman G, Milojevic M, Raffa G, ... Shah A, D\'Alessandro DA

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management, and avoidance of complications, appraisal of new approaches and ethics, education, and training.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Lorusso R, Whitman G, Milojevic M, Raffa G, ... Shah A, D'Alessandro DA
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33039139
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Impact:
Abstract

Association between coronary artery bypass graft center volume and year-to-year outcome variability: New York and California statewide analysis.

Mori M, Weininger GA, Shang M, Brooks C, ... Vallabhajosyula P, Geirsson A
Objective
We evaluated whether volume-based, rather than time-based, annual reporting of center outcomes for coronary artery bypass grafting may improve inference of quality, assuming that large center-level year-to-year outcome variability is related to statistical noise.
Methods
We analyzed 2012 to 2016 data on isolated coronary artery bypass grafting using statewide outcome reports from New York and California. Annual changes in center-level observed-to-expected mortality ratio represented stability of year-to-year outcomes. Cubic spline fit related the annual observed-to-expected ratio change and center volume. Volume above the inflection point of the spline curve indicated centers with low year-to-year change in outcome. We compared observed-to-expected ratio changes between centers below and above the volume threshold and observed-to-expected ratio changes between consecutive annual and biennial measurements.
Results
There were 155 centers with median annual volume of 89 (interquartile range, 55-160) for isolated coronary artery bypass grafting. The inflection point of observed-to-expected ratio variability was observed at 111 cases/year. Median year-to-year observed-to-expected ratio change for centers performing less than 111 cases (62 centers) was greater at 0.83 (0.26-1.59) compared with centers performing 111 cases or more (93 centers) at 0.49 (022-0.87) (P < .001). By aggregating the outcome over 2 years, centers above the 111-case threshold increased from 93 centers (60%) to 118 centers (76%), but the median observed-to-expected change for all centers was similar between annual aggregates at 0.70 (0.26-1.22) compared with observed-to-expected change between biennial aggregates at 0.54 (0.23-1.02) (P = .095).
Conclusions
Center-level, risk-adjusted coronary artery bypass grafting mortality varies significantly from one year to the next. Reporting outcomes by specific case volume may complement annual reports.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print
Mori M, Weininger GA, Shang M, Brooks C, ... Vallabhajosyula P, Geirsson A
J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print | PMID: 33070939
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Impact:
Abstract

Essential information on surgical heart valve characteristics for optimal valve prosthesis selection: Expert consensus document from the European Association for Cardio-Thoracic Surgery (EACTS)-The Society of Thoracic Surgeons (STS)-American Association for Thoracic Surgery (AATS) Valve Labelling Task Force.

Durko AP, Pibarot P, Atluri P, Bapat V, ... De Paulis R,

Comprehensive information on the characteristics of surgical heart valves (SHVs) is essential for optimal valve selection. Such information is also important in assessing SHV function after valve replacement. Despite the existing regulatory framework for SHV sizing and labelling, this information is challenging to obtain in a uniform manner for various SHVs. To ensure that clinicians are adequately informed, the European Association for Cardio-Thoracic Surgery (EACTS), The Society of Thoracic Surgeons (STS) and American Association for Thoracic Surgery (AATS) set up a Task Force comprised of cardiac surgeons, cardiologists, engineers, regulatory bodies, representatives of the International Organization for Standardization and major valve manufacturers. Previously, the EACTS-STS-AATS Valve Labelling Task Force identified the most important problems around SHV sizing and labelling. This Expert Consensus Document formulates recommendations for providing SHV physical dimensions, intended implant position and hemodynamic performance in a transparent, uniform manner. Furthermore, the Task Force advocates for the introduction and use of a standardized chart to assess the probability of prosthesis-patient mismatch and calls valve manufacturers to provide essential information required for SHV choice on standardized Valve Charts, uniformly for all SHV models.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 14 Oct 2020; epub ahead of print
Durko AP, Pibarot P, Atluri P, Bapat V, ... De Paulis R,
J Thorac Cardiovasc Surg: 14 Oct 2020; epub ahead of print | PMID: 33070936
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Impact:
Abstract

History of cancer and survival after coronary artery bypass grafting: Experiences from the SWEDEHEART registry.

Mennander AA, Nielsen SJ, Huhtala H, Dellgren G, Hansson EC, Jeppsson A
Objective
To explore the currently unknown association between history of cancer at the time of coronary artery bypass grafting (CABG) and long-term survival.
Methods
All patients (n = 82,137) undergoing isolated first-time CABG in Sweden during 1997-2015 were included in this retrospective population-based cohort study. Individual patient data from the SWEDEHEART registry and 4 other mandatory nationwide health care registries were merged. Multivariable Cox proportional hazards regression and competing risk models adjusted for age and gender were used to assess associations between history of cancer, and long-term all-cause, cardiovascular and cancer mortality. Median follow-up was 9.0 years (interquartile range, 4.8-13.1).
Results
Altogether, 6819 (8.3%) of the patients had a history of cancer. The annual prevalence increased from 3.8% in 1997 to 14.8% in 2015. Patients with a history of cancer were older (72 vs 66 years; P < .001) and had more comorbidities. Long-term all-cause mortality was significantly greater in patients with a history of cancer (45.7% vs 22.9% at 10 years; adjusted hazard ratio, 1.33; 95% confidence interval [CI], 1.28-1.38, P < .001). According to the competing risk models, history of cancer was associated with an increased risk for cancer death (subdistribution hazard ratio, 2.45; 95% CI, 2.28-2.63, P < .001) but not cardiovascular death (subdistribution hazard ratio, 0.88; 95% CI, 0.83-0.94, P < .001).
Conclusions
The proportion of patients undergoing CABG with a history of cancer has increased over time. History of cancer at the time of surgery is associated with increased cancer deaths over time but not cardiovascular deaths. The same cardiovascular prognosis after CABG can be expected regardless of cancer history.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Sep 2020; epub ahead of print
Mennander AA, Nielsen SJ, Huhtala H, Dellgren G, Hansson EC, Jeppsson A
J Thorac Cardiovasc Surg: 16 Sep 2020; epub ahead of print | PMID: 33069428
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Abstract

Reintervention rates after bioprosthetic pulmonary valve replacement in patients younger than 30 years of age: A multicenter analysis.

Baird CW, Chávez M, Sleeper LA, Borisuk MJ, ... Lu M, Fuller SM
Objectives
To assess the difference in time to and predictors of reintervention according to valve type in surgical bioprosthetic pulmonary valve replacement (PVR) in patients younger than 30 years of age from multiple centers.
Methods
Data were retrospectively collected for 1278 patients <30 years of age undergoing PVR at 8 centers between 1996 and 2015.
Results
Mean age at PVR was 19.3 ± 12.8 years, with 719 (56.3%) patients ≤18 years of age. Diagnosis was tetralogy of Fallot in 626 patients (50.5%) and 165 (12.9%) had previous PVR. Median follow-up was 3.9 years (interquartile range, 1.2, 6.4). Multiple valve types were used, most commonly CE PERIMOUNT, 488 (38.2%), CE Magna/Magna Ease, 361 (28.2%), and Sorin Mitroflow 322 (25.2). Reintervention occurred in 12.7% and was most commonly due to pulmonary stenosis (68.8%), with most reinterventions occurring in children (85.2%) and with smaller valve sizes (P < .001) Among adults aged 18 to 30 years, younger age was not a significant risk factor for reintervention. Surgical indication of isolated pulmonary regurgitation was associated with a lower risk of reintervention (P < .001). Overall, 1-, 3-, 5-, and 10-year freedom from reintervention rates were 99%, 97%, 92%, and 65%. The only independent risk factors for reintervention after controlling for age and valve size were lack of a concomitant tricuspid valve procedure (P = .02) and valve type (P < .001); Sorin and St Jude valves were associated with similar time to reintervention, and deteriorated more rapidly than other valve types.
Conclusions
In this large multicenter study, 8% of patients have undergone reintervention by 5 years. Importantly, independent of age and valve size, reintervention rates vary by valve type.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 09 Sep 2020; epub ahead of print
Baird CW, Chávez M, Sleeper LA, Borisuk MJ, ... Lu M, Fuller SM
J Thorac Cardiovasc Surg: 09 Sep 2020; epub ahead of print | PMID: 33069421
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Impact:
Abstract

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with reduced ejection fraction.

Bianco V, Kilic A, Mulukutla S, Gleason TG, ... Wang Y, Sultan I
Objective
The aim of this study was to evaluate comparative outcomes for percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with reduced ejection fraction.
Methods
All patients from the University of Pittsburgh Medical Center from 2011 to 2018 who had reduced preoperative ejection fraction (<50%) and underwent CABG or PCI for coronary revascularization were included in this study. Patients were risk-adjusted with propensity matching (1:1) and primary outcomes included long-term survival, readmission, and major adverse cardiac and cerebrovascular events (MACCE).
Results
A total of 2000 patients were included in the current study, consisting of CABG (n = 1553) and PCI (n = 447) cohorts with a mean ejection fraction of 35% ± 9.53%. Propensity matching yielded a 1:1 match with 324 patients in each cohort, controlling for all baseline characteristics. Thirty-day mortality was similar for PCI versus CABG (6.2% vs 4.9%; P = .49). Overall mortality over the study follow-up period (median, 3.23 years; range, 1.83-4.98 years) was significantly higher for the PCI cohort (37.4% vs 21.3%; P < .001). Total hospital readmissions (24.1% vs 12.9%; P = .001), cardiac readmissions (20.4% vs 11.1%; P = .001), myocardial infarction event (7.7% vs 1.8%; P = .001), MACCE (41.4% vs 23.8%; P < .001), and repeat revascularization (6.5% vs 2.6%; P = .02) occurred more frequently in the PCI cohort. Freedom from MACCE at 1 year (74.4% vs 87.0%; P < .001) and 5 years (54.5% vs 74.0%; P < .001) was significantly lower for the PCI cohort. On multivariable cox regression analysis, CABG (hazard ratio, 0.57; 95% confidence interval, 0.44-0.73; P < .001) was significantly associated with improved survival. Prior liver disease, dialysis, diabetes, and peripheral artery disease were the most significant predictors of mortality. The cumulative incidence of hospital readmission was lower for the CABG cohort (hazard ratio, 0.51; 95% confidence interval, 0.37-0.71; P < .001). Multivariable cox regression for MACCE (hazard ratio, 0.48; 95% confidence interval, 0.39-0.58; P < .001) showed significantly fewer events for the CABG cohort.
Conclusions
Patients with reduced ejection fraction who underwent CABG had significantly improved survival, lower MACCE, and fewer repeat revascularization procedures compared with patients who underwent PCI.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 15 Sep 2020; epub ahead of print
Bianco V, Kilic A, Mulukutla S, Gleason TG, ... Wang Y, Sultan I
J Thorac Cardiovasc Surg: 15 Sep 2020; epub ahead of print | PMID: 33059935
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Impact:
Abstract

Effect of previous coronary stenting on subsequent coronary artery bypass grafting outcomes.

Cheng YT, Chen DY, Chien-Chia Wu V, Chou AH, ... Chu PH, Chen SW
Objectives
The effect of previous coronary stenting on subsequent coronary artery bypass graft is inconclusive.
Methods
We used Taiwan\'s National Health Insurance Database to retrospectively evaluate patients with multivessel coronary artery bypass graft between January 2000 and December 2013. Overall, 32,335 patients who received coronary artery bypass graft were included, of whom 3028 had previous coronary stenting. Propensity-score matching yielded 2977 cases each for evaluation under the previous stenting and no stenting groups. The 30-day mortality and major adverse cardiac events, including all-cause mortality, acute myocardial infarction, and revascularization, were considered primary outcomes.
Results
The number of coronary artery bypass grafts decreased per year. However, the percentage of patients who had previous coronary stent implantation before coronary artery bypass graft increased steadily (P for trend <.001), and the average number of stents implanted in a patient also increased per year (P for trend <.001). The previous stent group had a significantly greater 30-day mortality rate than did the no-stent group (7.2% vs 5.0%; odds ratio, 1.47; 95% confidence interval, 1.19-1.82). The previous stent group had a greater rate of revascularization (14.4% and 10.0%; subdistribution hazard ratio, 1.50; 95% confidence interval, 1.30-1.74) in the last follow-up at year 13.
Conclusions
Previous coronary stenting before coronary artery bypass graft for multivessel coronary artery disease significantly increased 30-day mortality but did not affect late survival. However, patients who had coronary stenting before coronary artery bypass graft experienced more revascularization events during late follow-up.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print
Cheng YT, Chen DY, Chien-Chia Wu V, Chou AH, ... Chu PH, Chen SW
J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print | PMID: 33077179
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Impact:
Abstract

Outcomes and risk factors of late failure of valve-sparing aortic root replacement.

Patlolla SH, Saran N, Dearani JA, Stulak JM, ... King KS, Pochettino AB
Objective
Retention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation.
Methods
From January 1994 through June 2017, 342 patients (mean age 47.8 ± 15.5 years, 253 [74%] male) underwent VSARR. The most common etiologies were connective tissue disease (n = 143, 42%) followed by degenerative aortic aneurysm (n = 131, 38%). Aortic regurgitation (moderate or greater) was present in 35% (n = 119).
Results
Reimplantation technique was used in 90% patients (n = 308). Valsalva graft was used in 38% patients (n = 131) and additional cusp repair was done in 15% (n = 50). Operative mortality was 1% (n = 5). The median follow-up time was 8.79 years (interquartile range, 4.08-13.51). The cumulative incidence of reoperation (while accounting for the competing risk of death) was 8.4%, 12.8%, and 17.1% at 5, 10, and 15 years, respectively. There were no differences in survival and incidence of reoperation between root reimplantation and remodeling. Larger preoperative annulus diameter was associated with greater risk of reoperation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19, P = .01). The estimated probability of developing severe aortic regurgitation after VSARR was 8% at 10 years postoperatively. Operative mortality, residual aortic regurgitation at dismissal, and survival improved in recent times with more experience.
Conclusions
VSARR is a viable and safe option with good long-term outcomes and low rates of late aortic valve replacement. Dilated annulus preoperatively was associated with early repair failure.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print
Patlolla SH, Saran N, Dearani JA, Stulak JM, ... King KS, Pochettino AB
J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print | PMID: 33077178
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Impact:
Abstract

Outflow tract geometries are associated with adverse outcome indicators in repaired tetralogy of Fallot.

Shen WC, Chen CA, Chang CI, Chen YS, ... Wu MH, Wang JK
Objectives
A wide variety of right ventricular outflow tract (RVOT) and pulmonary artery (PA) geometries has been reported in patients with repaired tetralogy of Fallot (rTOF). We aimed to investigate the associations between RVOT/PA geometries and outcome indicators in a large rTOF cohort receiving non-conduit repair.
Methods
Three-dimensional magnetic resonance angiographic images of 206 patients with rTOF who had a pulmonary regurgitation (PR) fraction ≥20% were reviewed. Patients\' RVOT geometry was quantitatively classified into 4 distinct shapes (tubular, hourglass, pyramid, and inverted trapezoid). Bilateral PA size discrepancy was defined as the diameter of the smaller side being less than 70% of that of the bigger side.
Results
Based on lateral projection of the 3-dimensional images, patients with an inverted trapezoid-shaped RVOT had the smallest RV end-diastolic volume index (EDVi) (108.7 ± 24.3 mL/m) and pulmonary valve annulus diameter, and shortest QRS duration, whereas those with a pyramid-shaped RVOT had the largest RV EDVi (161.0 ± 44.6 mL/m) and pulmonary valve annulus diameter. Similar trends of differences were also observed if such classifications were based on the frontal projections. Multivariable analysis revealed that RVOT shapes, subvalvular diameter, PR fraction, QRS duration, and the presence of bilateral PA size discrepancy were independent determinants of RV EDVi. Furthermore, having bilateral PA size discrepancy (25.2%) was independently associated with lower peak oxygen consumption (P = .041).
Conclusions
Distinct RVOT morphologies and branch PA size discrepancy are associated with variations in RV remodeling and exercise capacity in patients with rTOF. These findings may aid decision-making regarding reintervention for PR and branch PA size discrepancy.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print
Shen WC, Chen CA, Chang CI, Chen YS, ... Wu MH, Wang JK
J Thorac Cardiovasc Surg: 21 Sep 2020; epub ahead of print | PMID: 33097218
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Impact:
Abstract

Bilateral internal thoracic artery grafting in elderly patients: Any benefit in survival?

Navia D, Espinoza J, Vrancic M, Piccinini F, ... Dorsa A, Seoane L
Objective
The purpose of the present study was to compare survival outcomes in propensity score-matched patients aged 70 years or greater receiving a bilateral internal thoracic artery graft with patients receiving a single internal thoracic artery graft.
Methods
Among 4083 consecutive patients with isolated coronary artery bypass grafting who underwent operation between January 2001 and December 2018, we identified 1300 patients aged 70 years or greater; of these, 968 received a bilateral internal thoracic artery (bilateral internal thoracic artery group) and 332 received a single internal thoracic artery (single internal thoracic artery group). Propensity score matching was used to reduce the preoperative patient differences. The 10-year survival and postoperative complications were compared between the 2 groups.
Results
A Kaplan-Meier curve at 10 years of follow-up showed that crude survival was significantly superior in patients with bilateral internal thoracic artery grafts than in patients with single internal thoracic artery grafts (67.0% ± 2.5% vs 56.0% ± 3.4%, respectively; P < .016). In the actuarial survival, estimates for propensity score-matched patients with a bilateral internal thoracic artery showed a significantly higher rates of survival than patients with a single internal thoracic artery by the end of follow-up (66.0% ± 5.3% vs 53.0% ± 3.9%, respectively; hazard ratio, 0.64; 95% confidence interval, 0.44-0.94; P = .022, univariable Cox Model and multivariable analysis hazard ratio, 0.66; 95% confidence interval, 0.45-0.97; P = .036 Cox model). Postoperative complications were all similar between the single internal thoracic artery and bilateral internal thoracic artery groups.
Conclusions
The use of bilateral internal thoracic artery grafting in older patients improves 10-year survival, with similar postoperative morbidity. This surgical technique might have beneficial effects in survival in patients aged more than 70 years. Its use could be considered more frequently.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 02 Oct 2020; epub ahead of print
Navia D, Espinoza J, Vrancic M, Piccinini F, ... Dorsa A, Seoane L
J Thorac Cardiovasc Surg: 02 Oct 2020; epub ahead of print | PMID: 33127090
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Impact:
Abstract

Unraveling the impact of time-dependent perioperative variables on 30-day readmission after coronary artery bypass surgery.

Manyam R, Zhang Y, Carter S, Binongo JN, Rosenblum JM, Keeling WB
Objectives
Readmission within 30 days of discharge after coronary artery bypass grafting is a measure of quality and a driver of cost in health care. Traditional predictive models use time-independent variables. We developed a new model to predict time to readmission after coronary artery bypass grafting using both time-independent and time-dependent preoperative and perioperative data.
Methods
Adults surviving to discharge after isolated coronary artery bypass grafting at a multi-hospital academic health system from January 2017 to September 2018 were included in this study. Two distinct data sources were used: the institutional cardiac surgical database and the clinical data warehouse, which provided more granular data points for each patient. Patients were divided into training and validation sets in an 80:20 ratio. We evaluated 82 potential risk factors using Cox survival regression and machine learning techniques. The area under the receiver operating characteristic curve was used to estimate model predictive accuracy.
Results
We trained the model with 21 variables that scored a P value of less than .05 in the univariable analysis. The multivariable model determined 16 significant risk factors, and 6 of them were time-dependent. These included preoperative hemoglobin a1c level, preoperative creatinine, preoperative hematocrit, intraoperative hemoglobin, postoperative creatinine, and postoperative hemoglobin. Area under the receiver operating characteristic values were 0.906 and 0.868 for training and validation sets, respectively.
Conclusions
Time-dependent perioperative variables in an isolated coronary artery bypass grafting cohort provided better predictive ability to a readmission model. This study was unique in the inclusion of time-dependent covariates in the predictive model for readmission after discharge after coronary artery bypass grafting.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Sep 2020; epub ahead of print
Manyam R, Zhang Y, Carter S, Binongo JN, Rosenblum JM, Keeling WB
J Thorac Cardiovasc Surg: 28 Sep 2020; epub ahead of print | PMID: 33127082
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Impact:
Abstract

Prognostic value of natriuretic peptides and restrictive filling pattern before surgical ventricular restoration.

Toso A, Castelvecchio S, Menicanti L, Volpe M, Fantini F
Objective
Both increased natriuretic peptide levels and restrictive filling pattern (RFP) are important risk predictors in patients with heart failure. The aim of this study was to examine the role of the combined use of natriuretic peptide and RFP for the prognostic stratification of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration in the Biomarker Plus study.
Methods
A total of 186 patients (aged 64 ± 10 years) underwent echocardiographic study and N-terminal pro-B-type natriuretic peptide assay at baseline (before surgical ventricular restoration). Patients were divided into 4 groups depending on baseline diastolic filling pattern (RFP/no RFP) and N-terminal pro-B-type natriuretic peptide level (less than or greater than or equal to the upper tertile value of 2003 ŋg/L). RFP was defined as E/A ratio ≥2. All-cause death or heart failure hospitalizations within 36-month follow-up were analyzed.
Results
Despite similar ejection fraction, volumes, and mass, the 4 groups presented distinct clinical and structural pattern of presurgical ventricular restoration ventricular remodeling and significantly different clinical outcome after surgical unloading. During follow-up, 67 patients died or were hospitalized for heart failure (36%). High N-terminal pro-B-type natriuretic peptide levels and RFP, considered individually, were significantly associated with outcome (P < .0001). The combination of both was associated with the highest adjusted hazard of adverse events (hazard ratio, 3.63; 95% CI, 1.73-7.6; P < .0001).
Conclusions
The simultaneous use of 2 markers, 1 biological and 1 echocardiographic, may allow better prognostic stratification and characterization of the distinct structural and clinical phenotypes in a population of patients with ischemic cardiomyopathy undergoing surgical ventricular restoration. This approach could be useful in the decision-making process to guide treatment choices in patients with ischemic cardiomyopathy.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 14 Oct 2020; epub ahead of print
Toso A, Castelvecchio S, Menicanti L, Volpe M, Fantini F
J Thorac Cardiovasc Surg: 14 Oct 2020; epub ahead of print | PMID: 33168168
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Impact:
Abstract

Long-term outcomes following Fontan takedown in Australia and New Zealand.

Marathe SP, Iyengar AJ, Betts KS, du Plessis K, ... d\'Udekem Y, Alphonso N
Objective
Fontan takedown remains an option for the management of Fontan failure. We sought to evaluate early and late outcomes after Fontan takedown.
Methods
The Australia and New Zealand Fontan Registry was interrogated to identify all patients who had a Fontan takedown.
Results
Over a 43-year study period (1975-2018), 36 of 1540 (2.3%) had a Fontan takedown. The median age at takedown was 5.1 years (interquartile range [IQR], 3.7, 7.0). Nine (25%) patients had a takedown within 48 hours, 6 (16%) between 2 days and 3 weeks, 14 (39%) between 3 weeks and 6 months, whereas 7 (19%) had a late takedown (>6 months). Median interval to takedown was 26 days (IQR, 1.5, 127.5). Sixteen (44%) patients died at a median of 57.5 days (IQR, 21.8, 76.8). The greatest mortality occurred between 3 weeks and 6 months (<2 days: 1/9, 11%; 2 days to 3 weeks: 2/6, 33%; 3 weeks to 6 months: 11/14, 79%; >6 months: 2/7, 28%; P = .007). At median follow-up of 9.4 years (IQR, 4.5, 15.3), 11 (31%) patients were alive with an intermediate circulation (10 in New York Heart Association class I/II). Five (14%) patients underwent a successful second Fontan. Freedom from death/transplant after Fontan takedown was 59%, 56%, and 52% at 1, 5, and 10 years, respectively.
Conclusions
The incidence of Fontan takedown is low, but mortality is high. The majority of takedowns occurred within 6 months. Mortality was lowest when takedown occurred <2 days and highest between 3 weeks and 6 months. A second Fontan is possible in a small proportion of survivors.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 05 Oct 2020; epub ahead of print
Marathe SP, Iyengar AJ, Betts KS, du Plessis K, ... d'Udekem Y, Alphonso N
J Thorac Cardiovasc Surg: 05 Oct 2020; epub ahead of print | PMID: 33131894
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Impact:
Abstract

Prognostic impact and distinctive characteristics of surgically resected anaplastic lymphoma kinase-rearranged lung adenocarcinoma.

Matsuura Y, Ninomiya H, Ichinose J, Nakao M, ... Nishio M, Mun M
Objective
Anaplastic lymphoma kinase (ALK) rearrangement is a representative lung cancer with driver mutation because of the efficacy of ALK-tyrosine kinase inhibitors. ALK-tyrosine kinase inhibitors are extensively used for ALK-rearranged lung cancer, whereas the therapeutic benefit of surgery remains unclear. Thus, we aimed to assess the clinical benefit of surgery in ALK-rearranged lung cancer and to elucidate the oncologic characteristics of ALK-rearranged lung cancer through surgically resected cases.
Methods
We retrospectively evaluated 1925 lung adenocarcinoma cases surgically resected between 1996 and 2017 at our institute. Moreover, 75 ALK-rearranged and 75 non-ALK-rearranged cases were extracted using propensity score matching. The survival rates, prognostic factors, and post-recurrence state were assessed.
Results
Multivariable analysis revealed that ALK rearrangement was an independent prognostic factor for improved cancer-specific survival (hazard ratio, 0.2; 95% confidence interval, 0.05-0.88; P = .033). In the matched cohort, the 5-year cancer-specific survival rates after surgery in the ALK-rearranged and non-ALK-rearranged groups were 97% and 77%, respectively. The ALK-rearranged group had a significantly better cancer-specific survival than did the non-ALK-rearranged group (log-rank test; P = .003). With respect to post-recurrence state, oligo-recurrence was highly frequent in the ALK-rearranged group, and post-recurrence survival was significantly improved by administration of either ALK-tyrosine kinase inhibitors (log-rank test; P = .011) or local ablative therapies (log-rank test; P = .035).
Conclusions
Surgically resected ALK-rearranged lung adenocarcinoma has excellent long-term outcome. Not only ALK-tyrosine kinase inhibitors but also a combination of local and systemic therapies may be important treatment strategies for ALK-rearranged lung adenocarcinoma even in the post-recurrence state.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 07 Oct 2020; epub ahead of print
Matsuura Y, Ninomiya H, Ichinose J, Nakao M, ... Nishio M, Mun M
J Thorac Cardiovasc Surg: 07 Oct 2020; epub ahead of print | PMID: 33131892
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Impact:
Abstract

Utility and safety of coronary angiography in patients with acute infective endocarditis who required surgery.

Spanneut TA, Paquet P, Bauters C, Modine T, ... Juthier F, Lemesle G
Objectives
To assess the benefit/risk ratio to perform a coronary angiography (CA) before surgery for infective endocarditis (IE).
Methods
We conducted a single-center prospective registry including 272 patients with acute IE intended for surgery and compared patients who underwent a preoperative CA (n = 160) with those who did not (n = 112). A meta-analysis of 3 observational studies was also conducted and included 551 patients: 342 who underwent a CA and 209 who did not.
Results
In our registry, combined bypass surgery (CABG) was performed in 17% of the patients with preoperative CA. At 2 years, the rate of the primary composite end point (all-cause death, new systemic embolism, stroke, new hemodialysis) was similar in the CA (38%) and no-CA (37%) groups. In-hospital and 2-year individual end points were all similar between groups. There were only 2 episodes of systemic embolism after CA and only one possibly related to a vegetation dislodgement. In the meta-analysis, combined CABG was performed in 18% of the patients with preoperative CA. All-cause death was similar in both groups: odds ratio, 0.98 [0.62-1.53], P = .92. Only 5 cases of systemic embolism possibly related to a vegetation dislodgement were reported. New hemodialysis was numerically more frequent in the CA group: odds ratio, 1.68 [0.79-3.58] (18% vs 14%, P = .18).
Conclusions
In daily practice, two-thirds of the patients with acute IE who required surgery have a preoperative CA leading to a combined CABG in 18% of the patients. Our results suggest that to perform a preoperative CA in this context is not associated with improved prognosis.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Spanneut TA, Paquet P, Bauters C, Modine T, ... Juthier F, Lemesle G
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33131891
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Impact:
Abstract

Aorta size mismatch predicts decreased exercise capacity in patients with successfully repaired coarctation of the aorta.

Mandell JG, Loke YH, Mass PN, Opfermann J, ... Krieger A, Olivieri LJ
Objective
Coarctation of the aorta (CoA) is associated with decreased exercise capacity despite successful repair with no residual stenosis; however, the hemodynamic mechanism remains unknown. This study aims to correlate aortic arch geometry with exercise capacity in patients with successfully repaired CoA and explain hemodynamic changes using 3-dimensional-printed aorta models in a mock circulatory flow loop.
Methods
A retrospective chart review identified patients with CoA repair who had cardiac magnetic resonance imaging and an exercise stress test. Measurements included aorta diameters, arch height to diameter ratio, left ventricular function, and percent descending aorta (%DAo) flow. Each aorta was printed 3-dimensionally for the flow loop. Flow and pressure were measured at the ascending aorta (AAo) and DAo during simulated rest and exercise. Measurements were correlated with percent predicted peak oxygen consumption (VO max).
Results
Fifteen patients (mean age 26.8 ± 8.6 years) had a VO max between 47% and 126% predicted (mean 92 ± 20%) with normal left ventricular function. DAo diameter and %DAo flow positively correlated with VO (P = .007 and P = .04, respectively). AAo to DAo diameter ratio (D/D) negatively correlated with VO (P < .001). From flow loop simulations, the ratio of %DAo flow in exercise to rest negatively correlated with VO (P = .02) and positively correlated with D/D (P < .01).
Conclusions
This study suggests aorta size mismatch (D/D) is a novel, clinically important measurement predicting exercise capacity in patients with successful CoA repair, likely due to increased resistance and altered flow distribution. Aorta size mismatch and %DAo flow are targets for further clinical evaluation in repaired CoA.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Mandell JG, Loke YH, Mass PN, Opfermann J, ... Krieger A, Olivieri LJ
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33131888
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Impact:
Abstract

Implementation of a protocol to increase the academic productivity of cardiothoracic surgery resident physicians.

Coyan GN, Sultan I, Seese LM, Chu D, ... Kinnunen A, Kilic A
Objective
Academic productivity during cardiothoracic surgery residency training is an important program metric, but is highly variable due to multiple factors. This study evaluated the influence of implementing a protocol to increase resident physicians\' academic productivity in cardiac surgery.
Methods
A comprehensive protocol for cardiac surgery was implemented at our institution that included active pairing of residents with academically productive faculty, regular research meetings, centralized data storage and analysis with a core team of biostatisticians, a formal peer-review protocol for analytic requests, and project prioritization and feedback. We compared cardiothoracic surgery residents\' academic productivity before implementation (July 2015-June 2017) versus after implementation (July 2017-June 2019). Academic productivity was measured by peer-reviewed articles, abstract presentations (oral or poster) at national cardiothoracic surgery meetings, and textbook chapters.
Results
Thirty-four resident physicians (from traditional and integrated programs) trained at our institution during the study. A total of 122 peer-reviewed articles were produced over the course of the study: 74 (60.7%) cardiac- and 48 (39.3%) thoracic-focused. The number of cardiac-focused resident-produced articles increased from 10 preimplementation to 64 postimplementation (0.61 vs 2.03 articles per resident; P < .01). Abstract oral or poster presentations also increased, from 11 to 40 (0.61 vs 1.33 abstracts per resident; P = .01). Textbook chapters increased from 4 to 15 following the intervention (0.22 vs 0.5 chapters per resident; P = .01).
Conclusions
Implementation of a dedicated protocol to facilitate faculty mentoring of resident research and streamline the data access, analysis, and publication process substantially improved cardiothoracic surgery residents\' academic productivity.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Coyan GN, Sultan I, Seese LM, Chu D, ... Kinnunen A, Kilic A
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33131886
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Impact:
Abstract

Understanding thoracic surgeons\' perceptions of administrative database analyses and guidelines in clinical decision-making.

Shemanski KA, Farias A, Lieu D, Kim AW, ... Canter RJ, David EA
Objectives
This study explored cardiothoracic surgeons\' perceptions of health services research and practice guidelines, particularly how both influence providers\' clinical decision-making.
Methods
A trained interviewer conducted open-ended, semistructured phone interviews with cardiothoracic surgeons across the United States. The interviews explored surgeons\' experiences with lung cancer treatment and their perceptions of health services research and guidelines. Researchers coded the transcribed interviews using conventional content analysis. Interviews continued until thematic saturation was reached.
Results
The 27 surgeons interviewed mostly were general thoracic surgeons (23/27) who attend tumor board weekly (21/27). Five themes relating to physician perceptions of health services research and guidelines emerged. Databases analyses\' inherent selection bias and perceived deficit of pertinent clinical variables made providers skeptical of using these studies as primary decision drivers; however, providers thought that database analyses are useful to supplement other data and drive future research. Likewise, providers generally felt that although guidelines provide a useful framework, they often have difficulty applying guidelines to individual patients. An analysis of provider characteristics revealed that younger physicians in practice for fewer years appeared more likely to report using guidelines, and physicians who were aged 50 years or more and not purely academic surgeons appeared to find database analyses less impactful.
Conclusions
Health services research, including database analyses, comprise much of the surgical literature; however, this study suggests that perceptions of database analyses and guidelines are mixed and questions whether thoracic surgeons routinely use either to inform their decisions. Researchers must address how to present compelling data to influence clinical practice.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Sep 2020; epub ahead of print
Shemanski KA, Farias A, Lieu D, Kim AW, ... Canter RJ, David EA
J Thorac Cardiovasc Surg: 16 Sep 2020; epub ahead of print | PMID: 33139063
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Impact:
Abstract

Management of primary cardiac paraganglioma.

Chan EY, Ali A, Umana JP, Nguyen DT, ... MacGillivray TE, Reardon MJ
Objective
Cardiac paraganglioma is a rare tumor that most surgeons have limited experience treating. The objective of this study is to examine the management and outcomes for cardiac paraganglioma treatment when cared for by a multidisciplinary cardiac tumor team.
Methods
We reviewed our institutionally approved cardiac tumor database from March 2004 to June 2020 for cardiac paraganglioma. These prospectively collected data were retrospectively reviewed. Patient characteristics were presented for individual patients and as summary statistics. Demographic and clinical data were also reported as median and interquartile range for continuous variables and frequencies and proportions for categoric variables. Kaplan-Meier curves were used to depict the patient survival from surgery.
Results
There were 21 cases of primary cardiac paraganglioma, 19 of whom had surgical resection with 3 refusing offered surgery. Of 19 resected tumors, 13 originated from the left atrium and 6 originated from the roots of the pulmonary artery and the aorta. Complex procedures were required, including aortic and pulmonary root replacement and 8 autotransplants. All tumors had complete gross resection with no identifiable disease left behind, but 4 of these had microscopically positive margins. None of the patients had local recurrence of disease. There was 1 case of metastatic paraganglioma with death at 4 years postsurgery. Operative mortality was 10.6%. Survival from surgery was 88.2%, 71.8%, and 71.8% and 1, 5, and 10 years, respectively.
Conclusions
Cardiac paraganglioma presents a surgical challenge. Mortality and long-term survival after surgical resection are acceptable but may require complex resection and reconstruction.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 02 Oct 2020; epub ahead of print
Chan EY, Ali A, Umana JP, Nguyen DT, ... MacGillivray TE, Reardon MJ
J Thorac Cardiovasc Surg: 02 Oct 2020; epub ahead of print | PMID: 33148444
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Impact:
Abstract

Fast-track extubation after cardiac surgery in infants: Tug-of-war between performance and reimbursement?

Murin P, Weixler VHM, Romanchenko O, Schulz A, ... Berger F, Photiadis J
Objectives
To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery.
Methods
Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared.
Results
Of 717 infants (median age: 4 months, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group.
Conclusions
FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 07 Oct 2020; epub ahead of print
Murin P, Weixler VHM, Romanchenko O, Schulz A, ... Berger F, Photiadis J
J Thorac Cardiovasc Surg: 07 Oct 2020; epub ahead of print | PMID: 33162169
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Impact:
Abstract

The differential prognostic impact of spread through air spaces in early-stage lung adenocarcinoma after lobectomy according to the pT descriptor.

Jung W, Chung JH, Yum S, Kim K, ... Jheon S, Cho S
Objectives
We evaluated the differential prognostic impact of spread through air spaces (STAS) in early-stage lung adenocarcinoma after lobectomy according to the pT descriptor.
Methods
The study population included 506 patients who underwent lobectomy with mediastinal lymph node dissection for pT1b, pT1c, and pT2a adenocarcinoma between 2011 and 2016. We divided the study population into 2 groups according to STAS status, ie, STAS (+) versus STAS (-), and stratified them according to the pT descriptor. A Cox proportional hazard model and inverse probability of treatment weight-adjusted Kaplan-Meier curves were used to evaluate the prognostic impact of STAS on recurrence-free survival (RFS) and its independency in each stratum.
Results
Multivariable Cox proportional hazard regression analysis demonstrated that in pT1b and pT1c strata, STAS (+) patients had a 7.02-fold and 2.89-fold greater risk of recurrence than STAS (-) patients, respectively. However, in the pT2a stratum, STAS did not affect RFS. And the RFS of the STAS (+) pT1b/c strata was similar to that of the pT2a stratum. In the pT1b/c strata, inverse probability of treatment weighting-adjusted Kaplan-Meier curves also showed that RFS was significantly worse when STAS was present. Furthermore, the risks for locoregional and distant recurrence were both greater when STAS was present.
Conclusions
The presence of STAS increased the risk of recurrence independently from other poor prognostic factors in patients with pT1b/cN0M0 adenocarcinoma who underwent lobectomy, but not in pT2a patients. The presence of STAS in pT1b/cN0M0 adenocarcinoma was associated with a similar risk of recurrence to that of pT2aN0M0 adenocarcinoma.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Jung W, Chung JH, Yum S, Kim K, ... Jheon S, Cho S
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33158568
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Impact:
Abstract

Primary cardiac lymphoma.

Yin K, Brydges H, Lawrence KW, Wei Y, ... Reardon MJ, Dobrilovic N
Objective
This study aimed to understand the population-level treatment modalities and to evaluate the survival benefits of surgical resection in primary cardiac lymphoma.
Methods
We queried the Surveillance, Epidemiology, and End Results Program database, which covers 35% of the US population. Patients with a histologic diagnosis of primary cardiac lymphoma from 1973 to 2015 were included. Multivariable accelerated failure time regression was performed to evaluate the associations between clinical factors and overall survival.
Results
A total of 184 patients were identified. The median age was 68 years, 80% were White, and 46% were women. Diffuse large B-cell lymphoma (80%) was the most common histology, and the majority (65%) was low-stage lymphoma (Ann Arbor stage I or II). Median survival was 2.2 years. Seventy-three percent of patients received chemotherapy. Only 10% of patients received local resection or debulking. Multivariable analysis demonstrated that local resection or debulking was not independently associated with overall survival (adjusted hazard ratio, 0.67; 95% confidence interval, 0.30-1.48; P = .32). Instead, chemotherapy (adjusted hazard ratio, 0.4; 95% confidence interval, 0.23-0.69; P < .001) was independently associated with improved survival, whereas increasing age (adjusted hazard ratio of 5-year increment, 1.13; 95% confidence interval, 1.04-1.22; P <.001) and advanced stage (adjusted hazard ratio, 2.18; 95% confidence interval, 1.33-3.56; P < .001) were independently associated with worse survival.
Conclusions
Surgical resection was not independently associated with survival in patients with primary cardiac lymphoma. Chemotherapy was the predominant treatment option and associated with improved survival, whereas increasing age and advanced stage were independently associated with worse outcomes.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Yin K, Brydges H, Lawrence KW, Wei Y, ... Reardon MJ, Dobrilovic N
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33158567
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Impact:
Abstract

The Ross procedure in patients older than 50: A sensible proposition?

Chauvette V, Bouhout I, Tarabzoni M, Wong D, ... El-Hamamsy I,
Background
The Ross procedure offers several advantages in nonelderly adults; however, the optimal age cutoff remains undetermined. The aim of this study was to compare the safety and mid-term outcomes after the Ross procedure in adult patients age ≤50 years and those age >50 years.
Methods
Between 2011 and 2019, 497 consecutive patients (mean age, 47 ± 12 years; 73% male) underwent a Ross procedure in 5 Canadian centers and were followed prospectively. Of these patients, 232 (47%) were age >50 years (mean, 57 ± 4 years) and 265 (53%) were age ≤50 years (mean, 38 ± 10 years). Early and mid-term outcomes were compared between the 2 groups.
Results
Patients age >50 years had more comorbidities: diabetes (14% vs 4%; P < .01), chronic obstructive pulmonary disease (8% vs 2%; P < .01), and coronary artery disease (17% vs 3%; P < .01). In contrast, patients age ≤50 years had more redo surgeries (24% vs 8%; P < .01), pure aortic regurgitation (21% vs 6%; P < .01) and unicuspid valves (42% vs 9%; P < .01). In-hospital mortality was similar in the 2 groups (0.4% vs 0.4%; P = .99). There were no between-group differences in perioperative complications. The cumulative incidence of reintervention was similar at 6 years (>50 years: 0.7 ± 0.7%; ≤50 years: 4 ± 2%; P = .12). Survival at 6 years was 98 ± 2% in patient age >50 years versus 96 ± 2% in those age ≤50 years (P = .43), similar to the age- and sex-matched general population.
Conclusions
The Ross procedure is a safe operation in patients age >50 years and provides excellent hemodynamics, stable valve function, and restored survival at mid-term follow-up. In expert centers, it should be considered as an alternative in selected patients age >50 years.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 05 Oct 2020; epub ahead of print
Chauvette V, Bouhout I, Tarabzoni M, Wong D, ... El-Hamamsy I,
J Thorac Cardiovasc Surg: 05 Oct 2020; epub ahead of print | PMID: 33158565
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Impact:
Abstract

Three-year outcomes of the postapproval study of the AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation Trial.

McCarthy PM, Gerdisch M, Philpott J, Barnhart GR, ... Ndikintum N, Calkins H
Objectives
The Cox Maze IV operation is commonly performed concomitant with other cardiac operations and effectively reduces the burden of atrial fibrillation. Prospective randomized trials have reported outcomes early and at 12 months, but only single-center late durability results are available. As part of the postapproval process for a bipolar radiofrequency ablation system, we sought to determine early and midterm outcomes of patients undergoing the Cox Maze IV operation.
Methods
A prospective, multicenter, single-arm study of 363 patients (mean age, 70 years, 82% valve surgery) with nonparoxysmal atrial fibrillation (mean duration, 60 months, 94% Congestive heart failure, Hypertension, Age ≥ 75, Diabetes, Stroke, VAScular disease, Age 65-74, Sex category ≥2) undergoing concomitant Maze IV atrial fibrillation ablation at 40 sites with 70 surgeons was performed between June 2010 and October 2014. Compliance with the study lesion set was 94.5%, and 99% had left atrial appendage closure. Freedom from atrial fibrillation was determined by extended monitoring, with a 48-hour Holter monitor minimum.
Results
There were no device-related complications. Freedom from atrial fibrillation off antiarrhythmic medications at 1, 2, and 3 years was 66%, 65%, and 64%, respectively, and including those using antiarrhythmics was 80%, 78%, and 76%, respectively. Warfarin was used in 49%, 44%, and 40%, respectively.
Conclusions
In patients with nonparoxysmal atrial fibrillation, compliance with the protocol was high, and freedom from atrial fibrillation off antiarrhythmics was high and sustained to 3 years. The safety and effectiveness of the system and Cox Maze IV procedure support the Class I guideline recommendation for concomitant atrial fibrillation ablation in patients undergoing cardiac surgery.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 02 Oct 2020; epub ahead of print
McCarthy PM, Gerdisch M, Philpott J, Barnhart GR, ... Ndikintum N, Calkins H
J Thorac Cardiovasc Surg: 02 Oct 2020; epub ahead of print | PMID: 33129501
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Impact:
Abstract

Factors associated with short- versus long-term survival after lung transplant.

Jawitz OK, Raman V, Becerra D, Klapper J, Hartwig MG
Objective
A small but growing proportion of lung transplant recipients survive longer than a decade post-transplant. The aim of this study was to identify factors associated with survival beyond a decade after lung transplant.
Methods
We queried the United Network for Organ Sharing registry for adult (age ≥18 years) recipients undergoing first-time isolated lung transplantation between the introduction of the Lung Allocation Score in 2005 and 2009. Recipients were stratified into 3 cohorts: those who survived less than 1 year, 1 to 10 years, and greater than 10 years. Multivariable logistic regression was used to identify factors independently associated with early mortality (<1 year) and long-term (>10 years) survival.
Results
A total of 5171 lung transplant recipients and their associated donors met inclusion criteria, including 964 (18.6%) with early mortality, 2843 (55.0%) with intermediate survival, and 1364 (26.3%) long-term survivors. Factors independently associated with early mortality included donor Black race, cigarette use, arterial oxygen partial pressure/fractional inspired oxygen ratio, diabetes, recipient Lung Allocation Score, total bilirubin, extracorporeal membrane oxygenation bridge requirement, single lung transplantation, and annual lung transplant center volume. The only factors independently associated with long-term survival among those who survived at least 1 year was donor age and single lung transplantation.
Conclusions
Of patients undergoing lung transplantation after the implementation of the Lung Allocation Score, approximately one-quarter survived 10 years post-transplant. There was minimal overlap between the factors associated with 1-year and 10-year survival. Of note, the Lung Allocation Score was not associated with long-term survival. Further research is needed to better refine patient selection and optimize management strategies to increase the number of long-term survivors.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Jawitz OK, Raman V, Becerra D, Klapper J, Hartwig MG
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33168166
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Impact:
Abstract

A multiparameter algorithm to guide repair of degenerative mitral regurgitation.

McCarthy PM, Herborn J, Kruse J, Liu M, Andrei AC, Thomas JD
Purpose
Degenerative mitral regurgitation repair using a measured algorithm could increase the precision and reproducibility of repair outcomes.
Methods
Direct and echocardiographic measurements guide the repair to achieve a coaptation length of 5 to 10 mm and minimize the risk of systolic anterior motion. Leaflet reconstruction restored the normal 2 to 1 ratio of anterior to posterior leaflet length without residual prolapse or restriction. The choice of ring size was based on anterior leaflet length, the distance from the leaflet coaptation point to the septum, and the anterior-posterior ring dimension. Freedom from reoperation and mitral regurgitation recurrence were based on multistate models.
Results
One thousand fifty-one patients had mitral surgery and 1026 (97.6%) were repaired. A2 length was 27.2 ± 4.5 mm; and the reconstructed posterior leaflet was 13.9 ± 2.3 mm. Median ring size was 34 mm and strongly correlated to A2 length (R = 0.76; P < .001). The coaptation length at P2 after repair was 6.4 ± 1.7 mm and 87% of measurements were between 5 and 10 mm. Results at predischarge and 10 years, respectively, included mild regurgitation (7.5% and 26.1%), moderate (0.7% and 15.6%), moderate to severe (0% and 1.4%), and severe (0% and 0%), with mean mitral gradient values 3.5 ± 1.5 and 2.9 ± 1.2 mm Hg, respectively. Systolic anterior motion at discharge and last follow-up were 0.2% and 1.1%, respectively. Ten-year freedom from mitral valve reoperation was 99.7%.
Conclusions
A simple, reproducible, measured algorithm for degenerative mitral valve repair provides excellent early and late results and is a useful adjunct to established surgical techniques.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Oct 2020; epub ahead of print
McCarthy PM, Herborn J, Kruse J, Liu M, Andrei AC, Thomas JD
J Thorac Cardiovasc Surg: 09 Oct 2020; epub ahead of print | PMID: 33168163
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Impact:
Abstract

Is there referral bias in outcomes of septal myectomy for hypertrophic cardiomyopathy?

Calderon-Rojas R, Nguyen A, Nishimura RA, Geske JB, ... Dearani JA, Schaff HV
Purpose
To determine the potential impact of referral bias on short- and long-term outcomes following septal myectomy for hypertrophic cardiomyopathy.
Methods
We reviewed 2303 adult patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy from January 1993 to April 2016. Patients were divided into 3 groups according to their permanent address: local (state) residents (n = 324), regional (surrounding 5 states) patients (n = 515), and national (outside 5 states) patients (n = 1464).
Results
Patient groups were similar for age, sex, preoperative New York Heart Association class, and left ventricular ejection fraction. Local patients had increased prevalence of diabetes mellitus (13%, 11%, 8%; P = .006), coronary artery disease (25%, 21%, 19%; P = .031), severe chronic lung disease (2.3%, 1.9%, 0.4%; P < .001), and atrial fibrillation (24%, 18%, 19%; P = .045) when compared with regional and national patients. Echocardiographic features did not differ between the 3 groups, including prevalence of moderate or greater mitral regurgitation (59%, 61%, 56%; P = .161). Local and regional patients were more likely to undergo concomitant procedures than national patients (P < .001). Mitral valve surgery was performed in 9.6% of the patients, more commonly in local and regional patients (12%, 12%, 8%; P = .018). There were 11 operative deaths (0.5%), and early mortality was similar among the groups. Geographic origin did not impact overall late survival.
Conclusions
Compared with distant referrals, local patients who undergo septal myectomy at our institution have more comorbid conditions, and require more concomitant surgical procedures. Despite these differences, referral patterns did not impact early or late outcomes following transaortic septal myectomy.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Oct 2020; epub ahead of print
Calderon-Rojas R, Nguyen A, Nishimura RA, Geske JB, ... Dearani JA, Schaff HV
J Thorac Cardiovasc Surg: 08 Oct 2020; epub ahead of print | PMID: 33190872
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Impact:
Abstract

Fetal brain growth and risk of postnatal white matter injury in critical congenital heart disease.

Peyvandi S, Lim JM, Marini D, Xu D, ... McQuillen P, Seed M
Objective
To test the hypothesis that delayed brain development in fetuses with d-transposition of the great arteries or hypoplastic left heart syndrome heightens their postnatal susceptibility to acquired white matter injury.
Methods
This is a cohort study across 3 sites. Subjects underwent fetal (third trimester) and neonatal preoperative magnetic resonance imaging of the brain to measure total brain volume as a measure of brain maturity and the presence of acquired white matter injury after birth. White matter injury was categorized as no-mild or moderate-severe based on validated grading criteria. Comparisons were made between the injury groups.
Results
A total of 63 subjects were enrolled (d-transposition of the great arteries: 37; hypoplastic left heart syndrome: 26). White matter injury was present in 32.4% (n = 12) of d-transposition of the great arteries and 34.6% (n = 8) of those with hypoplastic left heart syndrome. Overall total brain volume (taking into account fetal and neonatal scan) was significantly lower in those with postnatal moderate-severe white matter injury compared with no-mild white matter injury after adjusting for age at scan and site in d-transposition of the great arteries (coefficient: 14.8 mL, 95% confidence interval, -28.8 to -0.73, P = .04). The rate of change in total brain volume from fetal to postnatal life did not differ by injury group. In hypoplastic left heart syndrome, no association was noted between overall total brain volume and change in total brain volume with postnatal white matter injury.
Conclusions
Lower total brain volume beginning in late gestation is associated with increased risk of postnatal moderate-severe white matter injury in d-transposition of the great arteries but not hypoplastic left heart syndrome. Rate of brain growth was not a risk factor for white matter injury. The underlying fetal and perinatal physiology has different implications for postnatal risk of white matter injury.

Copyright © 2020 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 30 Sep 2020; epub ahead of print
Peyvandi S, Lim JM, Marini D, Xu D, ... McQuillen P, Seed M
J Thorac Cardiovasc Surg: 30 Sep 2020; epub ahead of print | PMID: 33185192
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Impact:
Abstract

Comparison of cancer control between segmentectomy and wedge resection in patients with clinical stage IA non-small cell lung cancer.

Tsutani Y, Handa Y, Shimada Y, Ito H, ... Yoshimura K, Okada M
Objective
The study objective was to compare cancer control between segmentectomy and wedge resection in patients with clinical stage IA non-small cell lung cancer.
Methods
Between 2010 and 2015, 457 patients with clinical stage IA (8th edition) non-small cell lung cancer undergoing wedge resection or segmentectomy were identified at 3 institutions. Propensity scores were calculated on the basis of the extent of resection (wedge resection or segmentectomy) and included adjustment for confounding variables, such as age, sex, smoking status, pulmonary functions, laterality, tumor size, maximum standardized uptake value on F-fluorodeoxyglucose positron emission tomography, presence of ground-glass opacity on high-resolution computed tomography, histology, and visceral pleural invasion for multivariable analysis and matching. The primary end point was cumulative incidence of recurrence.
Results
In all cohorts, postoperative recurrence occurred in 36 of 195 patients (18.5%) undergoing wedge resection and 14 of 262 patients (5.3%) undergoing segmentectomy. Cumulative incidence of recurrence was significantly lower in patients undergoing segmentectomy (5-year cumulative incidence of recurrence, 5.3%) than in those undergoing wedge resection (5-year cumulative incidence of recurrence, 19.1%; P < .001). In propensity score-adjusted multivariable analysis, segmentectomy was identified as an independent favorable prognostic factor for cumulative incidence of recurrence (hazard ratio, 0.47; 95% confidence interval, 0.24-0.90; P = .022). In propensity score matching of 163 pairs, cumulative incidence of recurrence was significantly lower in patients undergoing segmentectomy (5-year cumulative incidence of recurrence, 6.6%) than in those undergoing wedge resection (5-year cumulative incidence of recurrence, 13.2%; P = .041).
Conclusions
Cancer control was better in segmentectomy than in wedge resection. Segmentectomy is the preferred oncologic procedure as sublobar resection to treat clinical stage IA non-small cell lung cancer.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Oct 2020; epub ahead of print
Tsutani Y, Handa Y, Shimada Y, Ito H, ... Yoshimura K, Okada M
J Thorac Cardiovasc Surg: 21 Oct 2020; epub ahead of print | PMID: 33213872
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Impact:
Abstract

Adjunctive endovascular balloon fracture fenestration for chronic aortic dissection.

Levack MM, Kindzelski BA, Miletic KG, Vargo PR, ... Blackstone EH, Roselli EE
Objective
Positive remodeling after thoracic endovascular aortic repair (TEVAR) for chronic thoracic aortic dissection is variable due to incomplete distal seal and retrograde false lumen perfusion. We assessed the outcomes of adjunctive balloon fracture fenestration (BFF) during TEVAR in patients with chronic aortic dissection complicated by negative remodeling.
Methods
From June 2013 to January 2016, 49 patients with chronic aortic dissection complicated by aneurysm due to negative remodeling underwent TEVAR with BFF. Contrast-enhanced computed tomography was performed before discharge, at 3 to 6 months, and annually.
Results
Intraoperatively, endovascular stent graft expansion was achieved in all patients. There was 1 hospital death due to visceral malperfusion related to acute-on-chronic dissection noted before planned BFF. There were no occurrences of paraplegia, 3 patients had stroke, and 3 had acute renal failure. Survival at 1 year was 91%. Late reintervention for incomplete false lumen exclusion was required in 16 patients and freedom from reintervention was 75% at 1 year. Thirty-six patients (73.5%) had complete false lumen thrombosis through the treated segment. True lumen area increased following TEVAR with BFF and continued to incrementally expand with subsequent aortic remodeling at 1-year follow-up. Thirteen patients had positive remodeling, defined as thrombosis of false lumen, ≥10% decrease in aortic dimension, and ≥10% increase in true lumen diameter. Patients with positive remodeling had an average decrease of 11 mm in maximal aortic diameter at final follow-up.
Conclusions
BFF of chronic dissection membrane is a beneficial adjunct to TEVAR during short-term follow-up and may promote positive aortic remodeling and is worthy of further study.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print
Levack MM, Kindzelski BA, Miletic KG, Vargo PR, ... Blackstone EH, Roselli EE
J Thorac Cardiovasc Surg: 06 Oct 2020; epub ahead of print | PMID: 33220972
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Impact:
Abstract

Priming protects the spinal cord in an experimental aortic occlusion model.

Honkanen HP, Mustonen C, Herajärvi J, Tuominen H, ... Anttila V, Juvonen T
Objectives
Paraplegia is a devastating complication in aortic aneurysm surgery. Modifying the spinal cord vasculature is a promising method in spinal cord protection. The aim of this study was to assess whether the spinal cord can be primed by occluding thoracic segmental arteries before simulated aneurysm repair in a porcine model.
Methods
Twelve piglets were randomly assigned to the priming group (6) and the control group (6). Eight uppermost thoracic segmental arteries were occluded at 5-minute intervals in the priming group before a 25-minute aortic crossclamp. In the control group, the aorta was crossclamped for 25 minutes. During the first 5 minutes, 8 segmental arteries were occluded. After the aortic crossclamping, piglets were observed under anesthesia for 5 hours and followed up 5 days postoperatively. Near-infrared spectroscopy, motor-evoked potentials, blood samples, neurology with the modified Tarlov score, and histopathology of the spinal cord were assessed.
Results
The median Tarlov score during the first postoperative day was higher in the priming group than in the control group (P = .001). At the end, 50% of the control animals had paraplegia compared with 0% of paraplegia in the priming group. The mean regional histopathologic score differed between the priming group and the control group (P = .02). The priming group had higher motor-evoked potentials during the operation at separate time points. The lactate levels were lower in the priming group compared with the control group (P = .001, P = .18).
Conclusions
Acute priming protects the spinal cord from ischemic injury in an experimental aortic crossclamp model.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Oct 2020; epub ahead of print
Honkanen HP, Mustonen C, Herajärvi J, Tuominen H, ... Anttila V, Juvonen T
J Thorac Cardiovasc Surg: 21 Oct 2020; epub ahead of print | PMID: 33220965
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Impact:
Abstract

Preoperative left atrial strain abnormalities are associated with the development of postoperative atrial fibrillation following isolated coronary artery bypass surgery.

Kislitsina ON, Cox JL, Shah SJ, Malaisrie SC, ... Andrei AC, McCarthy PM
Objective
Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG). Currently, there is no reliable way to determine preoperatively which patients will develop POAF following CABG. The aim of this study was to determine whether preoperative left atrial (LA) strain analysis might identify patients destined to develop POAF following CABG.
Methods
From 2016 to 2018, 211 patients who had a preoperative left ventricular ejection fraction >50% and adequate preoperative, predischarge, and follow-up echo images for interpretation underwent isolated CABG surgery. Postoperatively, patients had continuous rhythm monitoring until hospital discharge. Retrospective speckle-tracking analysis of preoperative echocardiograms was performed to calculate preoperative left ventricular global longitudinal strain and LA compliance and contraction strains in 92 matched patients. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of POAF after CABG.
Results
POAF occurred in 50 patients (24%). They were older, had longer intensive care unit and hospital stays, and a slightly greater 30-day mortality (P = .07). Preoperative LA volume index was larger in the patients with POAF but still \"normal\" as defined by current guidelines. However, preoperative LA compliance and contraction strains were significantly lower in patients who developed POAF after CABG.
Conclusions
Decreased preoperative LA strain measurements, especially LA-fractional area change, LA-emptying fraction, and LA-reservoir strain, taken jointly, are more specific and sensitive than other preoperative parameters in identifying patients who will develop POAF following CABG. The ability to identify patients preoperatively who are destined to develop POAF following CABG provides a basis for limiting POAF prophylactic therapy to only those patients undergoing CABG who are most likely to benefit from it rather than to all patients undergoing CABG.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Oct 2020; epub ahead of print
Kislitsina ON, Cox JL, Shah SJ, Malaisrie SC, ... Andrei AC, McCarthy PM
J Thorac Cardiovasc Surg: 09 Oct 2020; epub ahead of print | PMID: 33220963
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Impact:
Abstract

Cardiac surgery outcomes in patients with coronavirus disease 2019 (COVID-19): A case-series report.

Fattouch K, Corrao S, Augugliaro E, Minacapelli A, ... Argano C, Moscarelli M
Objective
The impact of coronavirus disease 2019 (COVID-19) on the postoperative course of patients after cardiac surgery is unknown. We experienced a major severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in our cardiac surgery unit, with several patients who tested positive early after surgery. Here we describe the characteristics, postoperative course, and laboratory findings of these patients, along with the fate of the health care workers. We also discuss how we reorganize and reallocate hospital resources to resume the surgical activity without further positive patients.
Methods
After diagnosis of the first symptomatic patient, surgery was suspended. Nasopharyngeal swabs were performed in all patients and health care workers. Patients who were positive for SARS-CoV-2 were isolated and monitored throughout the in-hospital stay and followed up after discharged until death or clinical recovery.
Results
Twenty patients were found to be positive for SARS-CoV-2 sometime after cardiac surgery (mean age 69 ± 10.4 years; median European System for Cardiac Operative Risk Evaluation II score 3 [interquartile range, 5.1]); the median time from surgery to diagnosis was 15 days (interquartile range, 11). Among the patients, 18 had undergone cardiac surgery and 2 of them transcatheter aortic valve replacement. Overall mortality was 15%. Specific COVID-19-related symptoms were identified in 7 patients (35%). Among the 12 health care workers infected, 1 developed a bilateral mild-grade interstitial pneumonia.
Conclusions
COVID-19 infection after cardiac surgery, regardless the time of the onset, is a serious condition. The systemic inflammatory state that follows extracorporeal circulation may mask the typical COVID-19 laboratory findings, making the diagnosis more difficult. A strict reorganization of the hospital resources is necessary to safely resume the cardiac surgical activity.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Oct 2020; epub ahead of print
Fattouch K, Corrao S, Augugliaro E, Minacapelli A, ... Argano C, Moscarelli M
J Thorac Cardiovasc Surg: 21 Oct 2020; epub ahead of print | PMID: 33220960
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Impact:
Abstract

Progression in Fontan conduit stenosis and hemodynamic impact during childhood and adolescence.

Patel ND, Friedman C, Herrington C, Wood JC, Cheng AL
Objective
To characterize changes in Fontan conduit size over time and determine if cross-sectional area (CSA) affects cardiac output, pulmonary artery growth, and exercise capacity.
Methods
We conducted a retrospective cross-sectional study of patients with Fontan physiology who underwent cardiac magnetic resonance imaging or cardiac catheterization between January 2013 and October 2019. We collected Fontan and pulmonary artery measurements, hemodynamic data, and cardiopulmonary exercise test data. We identified 158 patients with an extracardiac Fontan. We measured minimum and mean Fontan conduit CSA and assessed whether these correlated with Nakata index, cardiac index, or exercise capacity.
Results
Minimum Fontan CSA decreased by a median of 33% (24%, 40%) during a mean follow-up of 9.6 years. Median percentage decrease in Fontan CSA did not differ among 16-, 18-, and 20-mm conduits (P = .29). There was a significant decrease in the minimum Fontan CSA (33% [25%, 41%]) starting less than 1-year post-Fontan. Median Nakata index was 177.6 mm/m (149.1, 210.8) and was not associated with Fontan CSA/BSA (ρ = 0.09, P = .29). Fontan CSA/BSA was not associated with cardiac index (ρ = -0.003, P = .97). A larger Fontan CSA/BSA had a modest correlation with % predicted oxygen consumption (ρ = 0.31, P = .013).
Conclusions
Fontan conduit CSA decreases as early as 6 months post-Fontan. The minimum Fontan CSA/BSA was not associated with cardiac index or pulmonary artery size but did correlate with % predicted peak oxygen consumption.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Oct 2020; epub ahead of print
Patel ND, Friedman C, Herrington C, Wood JC, Cheng AL
J Thorac Cardiovasc Surg: 28 Oct 2020; epub ahead of print | PMID: 33220959
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Impact:
Abstract

Extensive repair of acute type A aortic dissection through a partial upper sternotomy and using complete stent-graft replacement of the arch.

Xie XB, Dai XF, Fang GH, Qiu ZH, Jiang DB, Chen LW
Background
Partial upper sternotomy (mini-ER) can be used in some adult cardiac surgeries but is seldom performed in the treatment of acute type A aortic dissection (AAAD). This study aimed to assess the feasibility and short-term outcomes of complete stent-graft replacement of the arch with triple-branched stent graft for AAAD through a mini-ER.
Methods
From 2015 to 2018, 254 patients with AAAD underwent complete stent-graft replacement of the arch with a triple-branched stent graft. Replacement was performed with conventional full sternotomy (con-ER) in 142 patients and with mini-ER in the other 112 patients. Using propensity score matching, the clinical data were compared between 100 patients in the mini-ER group and 100 patients in the con-ER group.
Results
After propensity score matching, there were no significant between-group differences in aortic cross-clamp time, cardiopulmonary bypass time, or total operative time. The amount of mediastinal drainage and number of red blood cell units were significantly lower in the mini-ER group compared with the con-ER group (P < .001). The intubation time was significantly shorter in the mini-ER group (P < .001). The treatment costs were also lower in the mini-ER group (P < .001). There were no significant between-group differences in 30-day mortality (9% vs 8%; P > .99) or postoperative complications.
Conclusions
This study shows that extensive repair of AAAD through a mini-ER is feasible. It was superior to con-ER in terms of blood loss, postoperative ventilation time, and treatment costs.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 23 Oct 2020; epub ahead of print
Xie XB, Dai XF, Fang GH, Qiu ZH, Jiang DB, Chen LW
J Thorac Cardiovasc Surg: 23 Oct 2020; epub ahead of print | PMID: 33223195
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Impact:
Abstract

Early septal reduction therapy for patients with obstructive hypertrophic cardiomyopathy.

Cui H, Schaff HV, Geske JB, Lahr BD, ... Nishimura RA, Ommen SR
Objective
This study was conducted to determine the influence of early septal reduction therapy (SRT) after referral on survival in patients with obstructive hypertrophic cardiomyopathy.
Methods
We reviewed the patients with obstructive hypertrophic cardiomyopathy (resting pressure gradient ≥30 mm Hg or provoked pressure gradient ≥50 mm Hg) who were evaluated at our clinic from 2000 to 2012. Early SRT was defined as undergoing septal myectomy or alcohol septal ablation during the 6 months after index evaluation. Survival after the 6-month landmark period was analyzed in a multivariable Cox model.
Results
A total of 1351 patients were included in the landmark analysis. Patients who were more symptomatic and had received more medical treatment at index evaluation were more likely to undergo early SRT. Over a median follow-up period of 10.2 years, the survival was comparable (P = .207) but patients undergoing early SRT had, on average, improved survival compared with the medical treatment group (hazard ratio, 0.66; 95% confidence interval, 0.48-0.90) after adjustment by age and comorbidities. Further analysis revealed significant treatment heterogeneity, with increased benefit of early SRT seen in women (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), those who are in New York Heart Association functional class III or IV (hazard ratio, 0.52; 95% confidence interval, 0.36-0.76), and patients without diabetes (hazard ratio, 0.59; 95% confidence interval, 0.42-0.82).
Conclusions
In experienced hypertrophic cardiomyopathy centers, early SRT is similar to continued medical treatment for patients with obstructive hypertrophic cardiomyopathy. It appears to improve survival of female patients and those who are in New York Heart Association functional class III or IV.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Oct 2020; epub ahead of print
Cui H, Schaff HV, Geske JB, Lahr BD, ... Nishimura RA, Ommen SR
J Thorac Cardiovasc Surg: 27 Oct 2020; epub ahead of print | PMID: 33223194
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Impact:
Abstract

Medical malpractice litigations involving aortic dissection.

Palaniappan A, Sellke F
Objectives
Medical malpractice litigation arises when a discrepancy exists between a patient\'s expectation of acceptable medical care and the care the patient receives. Aortic dissection is a frequently misdiagnosed and often-fatal condition. The purpose of this study was to characterize trends of medical malpractice litigations arising from aortic dissection, investigate the etiology, and analyze predictive factors regarding the verdict.
Methods
The Westlaw legal database was used to compile relevant litigations from 1994 to 2019 across the United States. Each litigation was screened individually for inclusion, and after inclusion, descriptive factors were compiled, including patient data, litigation data, verdict data, and clinical outcomes data. The Fisher exact test was used to evaluate the significance of association between parameters and verdict type.
Results
In total, 135 unique litigations met criteria for inclusion, with a defendant verdict in 57% (n = 77), plaintiff verdict in 20% (n = 27), and settlements in 23% (n = 31). Plaintiffs most commonly cited a failure to diagnose as their reason for litigation in 64% (n = 87). Patient mortality was associated with a lower average plaintiff award, $1,892,781 versus $5,944,983, and a lower average settlement, $1,230,923 versus $2,250,000, than their surviving counterparts. California, Illinois, and Pennsylvania had the most cases filed. An alleged failure to test, failure to refer, failure to consult, incidence of a stroke, and incidence of an autopsy diagnosis were significantly associated with defendant verdicts and a failure to diagnose was significantly associated with plaintiff verdicts (P < .05).
Conclusions
Plaintiffs frequently cited a failure to timely diagnose, order diagnostic tests, and interpret diagnostic tests as reasons for litigations. Defendant verdicts were common, suggesting judicially acceptable standards of care are commonly satisfied.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Oct 2020; epub ahead of print
Palaniappan A, Sellke F
J Thorac Cardiovasc Surg: 28 Oct 2020; epub ahead of print | PMID: 33229180
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Abstract

Expanded indications for lung transplantation for pulmonary complications after hematopoietic stem cell transplantation.

Noguchi M, Chen-Yoshikawa TF, Arai Y, Kondo T, ... Takaori-Kondo A, Date H
Objectives
Pulmonary complications after hematopoietic stem cell transplantation (HSCT) are associated with poor survival and can be treated by lung transplantation (LT). However, the indications for LT in patients with pulmonary complications after HSCT remain unclear due to low number of cases. HSCT is frequently conducted for hematologic malignancies, which have different recurrence patterns from solid-organ malignancies. Some patients also experience ABO blood type changes post-HSCT. This study aimed to reassess the indication of LT for pulmonary complications post-HSCT, focusing on disease-free interval (DFI) and ABO-incompatibility.
Methods
Retrospective chart reviews were performed in patients who underwent LT for post-HSCT pulmonary complications. In patients with previous hematologic malignancy, indication was based on estimated recurrence rate instead of DFI. Donors were selected based on the recipient anti-A/B antibody profile rather than ABO type. Post-LT survival and complication rates were examined.
Results
Forty consecutive patients undergoing LT after HSCT (including 31 with previous hematologic malignancy) were analyzed. The median DFI between HSCT and LT was 64.5 months. Thirteen patients with previous hematologic malignancy had DFI <5 years but none experienced recurrence. There was no significant difference in 5-year post-LT survival between patients undergoing (74.7%) and not undergoing HSCT (68.4%). There was no significant difference in survival between patients with DFI ≥5 years (63.8%) and patients with DFI <5 years (83.3%). Five patients underwent LTs from major ABO-incompatible donors, but none developed incompatibility-related complications.
Conclusions
Indications based on estimated recurrence rates and recipients\' anti-A/B antibody profiles may increase the use of LT for patients after HSCT.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Oct 2020; epub ahead of print
Noguchi M, Chen-Yoshikawa TF, Arai Y, Kondo T, ... Takaori-Kondo A, Date H
J Thorac Cardiovasc Surg: 28 Oct 2020; epub ahead of print | PMID: 33229173
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Abstract

Transcarotid versus transthoracic access for transcatheter aortic valve replacement: A propensity-matched analysis.

Allen KB, Chhatriwalla AK, Saxon J, Hermiller J, ... Korngold E, Kirker E
Objective
Transcarotid access for transcatheter aortic valve replacement is emerging as an alternative to more traditional nonfemoral access options such as transapical or transaortic; however, comparative data are limited. The purpose of the study was to analyze outcomes after transcatheter aortic valve replacement using transcatheter compared with transthoracic (transapical/transaortic) access.
Methods
The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was queried for patients who underwent transcarotid, transapical, or transaortic transcatheter aortic valve replacement with the SAPIEN 3 (Edwards Lifesciences, Irvine, Calif) transcatheter heart valve between June 2015 and July 2019. Thirty-day unadjusted outcomes were evaluated, and propensity score matching and logistic regression were used to compare transcatheter access with transthoracic access.
Results
In the propensity-matched analysis, 667 transcarotid transcatheter aortic valve replacement procedures were compared with 1334 transthoracic procedures. Transcarotid transcatheter aortic valve replacement was associated with lower mortality (4.2% vs 7.7%, P = .004), less new-onset atrial fibrillation (2.2% vs 12.1%, P < .0001), fewer readmissions at 30 days (9.8% vs 16.1%, P = .0006), shorter median length of stay (3.0 vs 6.0 days, P < .0001), shorter median intensive care unit stay (25 vs 47.2 hours, P < .0001), and greater 30-day Kansas City Cardiomyopathy Questionnaire score improvement from baseline (25.1 vs 20.8, P = .007). Stroke (4.3% vs 3.7%, P = .44) and major vascular complications (1.4% vs 1.9%, P = .40) were similar.
Conclusions
Transcatheter aortic valve replacement using transcarotid access is associated with lower 30-day mortality, less atrial fibrillation, shorter intensive care unit and overall length of stay, fewer readmissions, greater improvement in Kansas City Cardiomyopathy Questionnaire scores, and no significant difference in stroke or major vascular complications compared with transthoracic access.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Oct 2020; epub ahead of print
Allen KB, Chhatriwalla AK, Saxon J, Hermiller J, ... Korngold E, Kirker E
J Thorac Cardiovasc Surg: 20 Oct 2020; epub ahead of print | PMID: 33229170
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Abstract

Residual tumor characteristics of esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy.

Tang H, Jiang D, Zhang S, Zeng Z, ... Yin J, Ge D
Objective
The study was to investigate the characteristics of residual tumors of esophageal squamous cell carcinoma after neoadjuvant chemoradiotherapy.
Methods
The resection specimens of 187 patients undergoing surgery after neoadjuvant chemoradiotherapy in Zhongshan Hospital of Fudan University were reevaluated. Tumor regression grade determined by residual tumor ratios was scored for each specific layer of the esophageal wall and all removed lymph nodes for 4 grades as tumor regression grade 1, 0% residual tumors, tumor regression grade 2, less than 10%; tumor regression grade 3, 10% to 50%; tumor regression grade 4, greater than 50%. The pretreatment pathologic tumor stage and pretreatment pathologic lymph node stage before neoadjuvant chemoradiotherapy were recorded reflecting the original depth of primary tumor and number of originally involved lymph nodes, respectively. According to regression directionality, regression pattern was classified into 4 categories as type I: regression toward the lumen, type II: regression toward the invasive front, type III: concentric regression, and type IV: scattered regression. Statistical analyses were performed using Mann-Whitney, chi-square, Cochran Q tests, and Kendall τ-b coefficient, appropriately.
Results
A total of 138 patients have residual tumors, and 97 patients (70.3%), 100 patients (72.5%), 89 patients (64.5%), 63 patients (45.7%), and 68 patients (49.3%) have malignant cells in mucosa, submucosa, muscularis propria, adventitia/surrounding stroma, and lymph nodes, respectively. A total of 115 patients (83.3%) had residual tumors in the mucosa or submucosa, but 63 (54.8%) were graded as tumor regression grade 2 with small amounts of tumors in these 2 layers, 9 patients (6.5%) had residual tumors only in the deep 2 layers, and 14 patients (10.1%) had residual tumors only in lymph nodes. Overall, 86 patients (62.7%) with residual tumors are difficult to identify via present techniques. In patients with tumors that involved all esophageal layers before neoadjuvant chemoradiotherapy, only muscularis propria contained residual tumors significantly more frequently than the adventitia/surrounding stroma (P < .001). The random type IV and nonrandom regression patterns of type I to III were comparable with 48.9% and 51.1%, respectively. In patients with positive lymph node before neoadjuvant chemoradiotherapy, only a small portion of patients (29.2%, 28/96) achieved ypN0 status (nodes pathological complete response), even worse than the primary lesions (33.6%, 63/187) in esophageal squamous cell carcinoma.
Conclusions
The small amount of viable tumor cells in the superficial layers, low pathological complete response rate of lymph nodes, and diverse regression patterns lead to difficulty of detecting residual tumors in esophageal squamous cell carcinoma.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Sep 2020; epub ahead of print
Tang H, Jiang D, Zhang S, Zeng Z, ... Yin J, Ge D
J Thorac Cardiovasc Surg: 16 Sep 2020; epub ahead of print | PMID: 33268125
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This program is still in alpha version.