Journal: J Thorac Cardiovasc Surg

Sorted by: date / impact
Abstract

Predictors of survival following surgical resection of limited-stage small cell lung cancer.

Zhou N, Bott M, Park BJ, Vallières E, ... Sepesi B, Small Cell Lung Cancer Working Group
Background
Adjuvant chemotherapy, postoperative radiation (PORT), and prophylactic cranial irradiation (PCI) have been individually examined in limited-stage small cell lung cancer (SCLC). There is a paucity of data on the effectiveness of each adjuvant treatment modality when used in combination after surgical resection of SCLC.
Methods
Data were collected from 5 cancer centers on all patients with limited-stage SCLC who underwent surgical resection between 1986 and 2019. Univariate and multivariable models were conducted to identify predictors of long-term outcomes, focusing on freedom from recurrence and survival benefit of adjuvant chemotherapy, PORT, and PCI.
Results
A total of 164 patients were analyzed. Multivariable Cox regression analysis did not identify any adjuvant therapies to significantly influence recurrence in this cohort. Specifically, PORT was not associated with a significant influence on locoregional recurrence and PCI was not significantly associated with intracranial outcomes. Adjuvant chemotherapy improved survival in all stage I through III disease (hazard ratio, 0.49; 95% confidence interval, 0.29-0.81; P = .005) and even in pathologically node negative patients (hazard ratio, 0.49; 95% confidence interval, 0.27-0.91; P = .024). Although PCI was found to improve survival in univariate analysis, it was not significant in a multivariable model. PORT was not found to affect survival on either univariate or multivariable analysis.
Conclusions
This is among the largest multi-institutional studies on surgically resected limited-stage SCLC. Our results highlight survival benefit of adjuvant chemotherapy, but did not identify a statistically significant influence from mediastinal PORT or PCI in our cohort. Larger prospective studies are needed to determine the benefit of PORT or PCI in a surgically resected limited-stage SCLC population.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:760-771.e2
Zhou N, Bott M, Park BJ, Vallières E, ... Sepesi B, Small Cell Lung Cancer Working Group
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:760-771.e2 | PMID: 33349449
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Abstract

Asymptomatic degenerative mitral regurgitation repair: Validating guidelines for early intervention.

Desai A, Thomas JD, Bonow RO, Kruse J, ... Cox JL, McCarthy PM
Introduction
Mitral repair for asymptomatic (New York Heart Association [NYHA] class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine outcomes for asymptomatic patients when compared with those with symptoms.
Methods
Between 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models.
Results
The proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II.
Conclusions
Mitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:981-994.e5
Desai A, Thomas JD, Bonow RO, Kruse J, ... Cox JL, McCarthy PM
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:981-994.e5 | PMID: 33419544
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Abstract

Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis.

Riggs KW, Zafar F, Jacobs ML, Jacobs JP, ... Bryant R, Tweddell JS
Objectives
Airway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database.
Methods
Index cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model.
Results
Of 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001).
Conclusions
Patients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1112-1121.e7
Riggs KW, Zafar F, Jacobs ML, Jacobs JP, ... Bryant R, Tweddell JS
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1112-1121.e7 | PMID: 33419543
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Abstract

Factors associated with unplanned reinterventions and their relation to early mortality after pediatric cardiac surgery.

Dorobantu DM, Ridout D, Brown KL, Rodrigues W, ... Tsang VT, Stoica SC
Objective
Unplanned reintervention (uRE) is used as an indicator of patient morbidity and quality of care in pediatric cardiac surgery. We investigated associated factors and early mortality after uREs.
Methods
Morbidity data were prospectively collected in 5 UK centers between 2015 and 2017; uRE included surgical cardiac, interventional transcatheter cardiac, permanent pacemaker, and diaphragm plication procedures. Mortality (30-day and 6-month) in uRE/no-uRE patients was reported before and after matching. Predicted 30-day mortality was calculated using the Partial Risk Adjustment in Surgery score.
Results
A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 146 uREs, resulting in an uRE rate of 4.7%. Partial Risk Adjustment in Surgery score, 30-day mortality and 6-month mortality in uRE and no-uRE groups were 2.4% versus 1.3%, 8.9% versus 1%, and 17.1% versus 2.4%, respectively. After matching, mortality at 6 months remained higher in uRE compared with no-uRE (12.2% vs 1.4%; P = .02; 74 pairs). In the uRE group, 21 out of 25 deaths at 6 months occurred when at least 1 additional postoperative complication was present. In multivariable analysis, neonatal age (P = .002), low weight (P = .009), univentricular heart (P < .001), and arterial shunt (P < .001) were associated with increased risk of uRE, but Partial Risk Adjustment in Surgery score was not (only in univariable analysis).
Conclusions
uREs are a relatively frequent complication after pediatric cardiac surgery and are associated with some patient characteristics, but not the Partial Risk Adjustment in Surgery risk score. Early mortality was higher after uRE, independent of preoperative factors, but linked to other postoperative complications.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1155-1166.e9
Dorobantu DM, Ridout D, Brown KL, Rodrigues W, ... Tsang VT, Stoica SC
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1155-1166.e9 | PMID: 33419533
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Abstract

Lessons from reoperations for mitral stenosis after mitral valve repair.

El-Eshmawi A, Sun E, Boateng P, Pandis D, ... Anyanwu A, Adams DH
Background
The durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes.
Methods
Using a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020.
Results
The mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%.
Conclusions
MS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:937-946
El-Eshmawi A, Sun E, Boateng P, Pandis D, ... Anyanwu A, Adams DH
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:937-946 | PMID: 33431213
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Abstract

Relation between functional coronary artery stenosis and graft occlusion after coronary artery bypass grafting.

Hwang HY, Paeng JC, Kang J, Jang MJ, Kim KB
Objectives
This study was conducted to evaluate graft patency rates during the 5 years after coronary artery bypass grafting according to the functional significance of the coronary artery stenosis, as determined by myocardial single-photon-emission computed tomography.
Methods
Two hundred ninety-five patients who underwent coronary artery bypass grafting using Y-composite grafts based on the in situ left internal thoracic artery, and in whom preoperative stress/rest myocardial single-photon-emission computed tomography and 1-year angiographies were available were enrolled. Seven hundred sixty-nine and 262 distal anastomoses were constructed to ischemic and nonischemic areas, respectively. One-year and 5-year angiographic occlusion rates were evaluated in all and 80.3% of study patients, respectively. Factors associated with graft occlusion were evaluated using generalized linear mixed-effects models.
Results
Overall 1- and 5-year graft occlusion rates were 4.3% (44 of 1031 distal anastomoses) and 5.5% (45 out of 820), respectively. The occlusion rates of grafts bypassed to vessels with functionally significant and insignificant stenosis were 2.7% (21 out of 769) and 8.8% (23 out of 262) at 1 year and were 4.0% (25 out of 618) and 9.9% (20 out of 202) at 5 years, respectively. Graft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis (odds ratio, 0.50; 95% confidence interval, 0.28-0.92). The odds ratio of the graft occlusion according to functional ischemia was lower and significant in grafts to arteries with intermediate stenosis (stenosis ≥70% but <90%; odds ratio, 0.34; 95% confidence interval, 0.13-0.93) whereas it was higher and insignificant in grafts to arteries with severe stenosis (≥90% stenosis; odds ratio, 0.76; 95% confidence interval, 0.33-1.72).
Conclusions
Graft occlusion during the 5 years after coronary artery bypass grafting was associated with the functional significance of coronary artery stenosis, particularly when the stenosis degree was not severe.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1010-1018.e1
Hwang HY, Paeng JC, Kang J, Jang MJ, Kim KB
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1010-1018.e1 | PMID: 33431208
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Abstract

Gender representation among leadership at national and regional cardiothoracic surgery organizational annual meetings.

Shemanski KA, Ding L, Kim AW, Blackmon SH, ... Starnes VA, David EA
Background
Increased attention has been dedicated to gender inequity at scientific meetings. This study evaluated the gender distribution of session leaders at cardiothoracic surgery national and regional meetings.
Methods
This is a descriptive study of the gender of peer-selected session leaders at 4 cardiothoracic surgery organizations\' annual meetings from 2015 to 2019. Session leaders included moderators, panelists, and invited discussants. Data from publicly available programs were used to generate a list of session leaders and organization leaders. The primary outcome measure was the proportion of female session leaders at annual meetings. Descriptive analyses were performed, including the Cochran-Armitage trend test for linear trends of proportions.
Results
A total of 679 sessions over 20 meetings were examined. Of the 3662 session leaders, 480 (13.1%) were women. The proportion of total female session leaders trended positively over time from 9.6% (56 of 581) in 2015 to 15.9% (169 of 1060) in 2019 (P = .001). Among specialty topic sessions, female session leaders were distributed as follows: adult cardiac, 6.9% (81 of 1172); congenital cardiac, 10.8% (47 of 437); and thoracic, 23.2% (155 of 668). The proportion of female session leaders trended significantly only for thoracic sessions (20.6% [21 of 102] in 2015 to 29.2% [58 of 199] in 2019; P = .02). More than one-half of the sessions (57.4%; 390 of 679) featured all-male session leadership.
Conclusions
Women remain underrepresented in leadership roles at cardiothoracic surgery organizational meetings. This may deter female applicants and has implications for female surgeons\' career trajectories; therefore, attention must be given to the potential for unconscious bias in leadership in cardiothoracic surgery.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:733-744
Shemanski KA, Ding L, Kim AW, Blackmon SH, ... Starnes VA, David EA
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:733-744 | PMID: 33431207
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Abstract

Trends in the traditional cardiothoracic surgery resident operative experience for cardiac cases: An analysis of Accreditation Council for Graduate Medical Education case logs.

Shah AM, Siddiqui E, Holmes SD, Okoh A, ... Kaushal S, Sambol J
Objective
To determine whether the changing cardiac landscape has affected traditional cardiothoracic surgery (CTS) resident case volume, particularly cardiac case volume.
Methods
The Accreditation Council for Graduate Medical Education (ACGME) case logs for traditional CTS residents from 2016 to 2019 were reviewed. Using linear and nonlinear regression, trends in the annual volume and proportion of CTS operations were examined.
Results
Overall, the average number of total and category-specific CTS resident cases have increased from 2016 to 2019. However, in general, the proportion of thoracic surgery cases has been increasing, and the proportion of cardiac surgery cases has been decreasing. In particular, the proportion of coronary atherosclerosis (-0.2546 per 100 cases/year; P < .001) and valvular heart disease (-0.319 per 100 cases/year; P < .001) procedures demonstrated the greatest downward trends. The average operative experience for residents has increased (28.8 cases/resident/year; P < .001), but cardiac track residents (22.24 cases/resident/year; P < .001) have had a smaller increase than thoracic track residents (35.04 cases/resident/year; P < .001). Nevertheless, cardiac track residents experienced an increase in their average proportion of cardiac cases (0.176 per 100 cases/year; P < .001) compared with average (-0.263 per 100 cases/year; P < .001) and thoracic track (-0.978 per 100 cases/year; P < .001) CTS residents, indicating specialization of the tracks.
Conclusions
The overall CTS resident operative experience has increased over the last several years, with cardiac cases increasing more slowly than thoracic cases. The analysis reveals that cardiac operative volume has been asymmetrically allocated to cardiac track residents, indicating a greater specialization of the tracks. Annual evaluation of CTS resident case volume will provide essential insight into the field.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1064-1075.e3
Shah AM, Siddiqui E, Holmes SD, Okoh A, ... Kaushal S, Sambol J
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1064-1075.e3 | PMID: 33436298
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Abstract

First in human experience with an epicardial beating heart device for secondary mitral regurgitation.

Thourani VH, George I, Rucinskas K, Kalinauskas G, ... Smith R, Mack MJ
Objective
We describe a novel, off-pump, epicardial implant that is intended to reshape both the mitral valve annulus and the left ventricle (LV) in those with secondary mitral regurgitation (MR).
Methods
Five patients underwent an epicardial implant with the Mitral Touch device (Mitre Medical Corp, Morgan Hill, Calif), during concomitant off-pump coronary artery bypass for secondary MR. The median age was 71.2 years; 4 patients had severe MR and 1 moderate. Patients were followed for 1 year with transthoracic echocardiography and computed tomography. Safety, cardiac remodeling, and MR were assessed by an independent core laboratory.
Results
One patient died within 30 days from nondevice-related organ failure and the remaining 4 survived through 1-year follow-up. Implant technical success was 100% and took an average of 52 minutes. Paired computed tomography showed mean left ventricular end-systolic volume remodeling at 1 and 12 months of -35% and -31%, respectively. They averaged left atrial end-systolic volume remodeling of -12% and -15% at 1 and 12 months. Right ventricular end-systolic volume changes of -19% and -8% and right atrial end-systolic volume remodeling of -5% and 1%, at the 1- and 12-month time points were noted. Regurgitant volume by transthoracic echocardiography decreased by 46% and 44% and the ejection fraction from 34.6% to 32.1% and 39.5%, at 1 and 12 months, respectively. There were no device-related complications reported to 1 year.
Conclusions
The Epicardial Mitral Touch System for Mitral Regurgitation (ENRAPT-MR) study demonstrates a first-in-man, off-pump, epicardial repair of secondary MR. Procedural safety and geometric correction of the mitral valve apparatus and LV was achieved. Further studies in the United States are underway.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:949-958.e4
Thourani VH, George I, Rucinskas K, Kalinauskas G, ... Smith R, Mack MJ
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:949-958.e4 | PMID: 33436291
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Abstract

Outcomes of treatment pathways in 240 patients with congenitally corrected transposition of great arteries.

Barrios PA, Zia A, Pettersson G, Najm HK, ... Karamlou T, Members of the ccTGA Working Group
Objective
Congenitally corrected transposition of the great arteries (ccTGA) encompasses a diverse morphologic cohort, for which multiple treatment pathways exist. Understanding surgical outcomes among various pathways and their determinants are challenged by limited sample size and follow-up, and heterogeneity. We sought to investigate these questions with a large cohort of ccTGA patients presenting at different ages and representing the full therapeutic spectrum.
Methods
Retrospective review of 240 patients diagnosed with ccTGA from Cleveland Clinic coupled with prospective cross-sectional follow-up. Forty-six patients whose definitive procedure was completed elsewhere were excluded. Time-related survival was described among treatment pathways using actuarial, time-varying covariate, and competing risks analyses. Temporal trends in longitudinal valve and ventricular function were assessed using nonlinear mixed-effects models.
Results
Median follow-up was 10 years. Seventy-nine patients with ccTGA underwent anatomic repair, 45 physiologic repair, 24 Fontan palliation, and 6 primary transplant. Forty patients managed expectantly had excellent long-term survival when considered from time of presentation, but benefited from failures captured following transition to physiologic repair or transplant. Morphologic right ventricular dysfunction after physiologic repair increased from 68% to 85% after 5 years, whereas morphologic left ventricular function was stable in anatomic repair, especially with early surgery. Transplant-free survival at 15 years for anatomic and physiologic repair was 80% and 71%, respectively.
Conclusions
Early anatomic repair may be preferable to physiologic repair for select ccTGA patients. Late attrition after physiologic repair represents failure of expectant management and progressive tricuspid valve and morphologic right ventricular dysfunction compared with anatomic repair, where morphologic left ventricular function is relatively preserved.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1080-1093.e4
Barrios PA, Zia A, Pettersson G, Najm HK, ... Karamlou T, Members of the ccTGA Working Group
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1080-1093.e4 | PMID: 33436290
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Abstract

Surgery for laryngotracheal stenosis: Improved results.

Maurizi G, Vanni C, Rendina EA, Ciccone AM, ... Venuta F, D\'Andrilli A
Objective
Laryngotracheal resection is still considered a challenging operation and few high-volume institutions have reported large series of patients in this setting. During the 5 years, novel surgical techniques as well as new trends in the intra- and postoperative management have been proposed. We present results of our increased experience with laryngotracheal resection for benign stenosis.
Methods
Between 1991 and May 2019, 228 consecutive patients underwent laryngotracheal resection for subglottic stenosis. One hundred eighty-three (80.3%) were postintubation, and 45 (19.7%) were idiopathic. Most of them (58.7%) underwent surgery during the past 5 years. At the time of surgery, 139 patients (61%) had received tracheostomy, laser, or laser plus stenting. The upper limit of the stenosis ranged between actual involvement of the vocal cords to 1.5 cm from the glottis.
Results
There was no perioperative mortality. Two hundred twenty-two patients underwent resection and anastomosis according to the Pearson technique; 6 patients with involvement of thyroid cartilage underwent resection and reconstruction with the laryngofissure technique. Airway resection length ranged between 1.5 and 8 cm (mean, 3.8 ± 0.8 cm) and it was >4.5 cm in 19 patients. Airway complication rate was 7.8%. Overall success of airway complication treatment was 83.3%. Definitive success was achieved in 98.7% of patients. Patients presenting with idiopathic stenosis or postcoma patients showed no increased failure rate.
Conclusions
Laryngotracheal resection for benign subglottic stenosis is safe and effective, and provides a very high rate of success. Careful intra- and postoperative management is crucial for a successful outcome.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:845-852
Maurizi G, Vanni C, Rendina EA, Ciccone AM, ... Venuta F, D'Andrilli A
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:845-852 | PMID: 33451851
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Abstract

Looking beyond the eyeball test: A novel vitality index to predict recovery after esophagectomy.

Tang A, Ahmad U, Raja S, Rappaport J, ... Blackstone EH, Murthy SC
Objectives
To (1) measure 4 physiologic metrics before esophagectomy, (2) use these in an index to predict composite postoperative outcome after esophagectomy, and (3) compare predictive accuracy of this index to that of the Fried Frailty Index and Modified Frailty Index.
Methods
Grip strength (kilograms), 30-second chair sit-stands (number), 6-minute walk distance (meters), and normalized psoas muscle area (cm2/m) were measured for 77 consenting patients from January 1, 2018, to April 1, 2019. Imbalanced random forest classification estimated probability of a composite postoperative outcome, which included mortality, respiratory complications, anastomotic leak, delirium, length of stay ≥14 days, discharge to nursing facility, and readmission. G-mean error was used to compare predictive accuracy among indexes.
Results
Median grip strength was 38 kg (25th-75th percentiles, 31-44), number of sit-stands 11 (10-14), psoas muscle area to height ratio 6.9 cm2/m (6.0-8.2), and 6-minute walk distance 407 m (368-451). There was generally weak correlation between these metrics, with the highest between 30-second sit-stands and 6-minute walk distance (r = 0.57). Age, degree of patient-reported exhaustion, and the 4 objective metrics comprised the Esophageal Vitality Index, which had a lower G-mean error of 32% (31-33) than the Fried Frailty Index, 37% (37-38), and the Modified Frailty Index, 48% (47-48).
Conclusions
The Esophageal Vitality Index, an objective, simple assessment consisting of grip strength, 30-second chair sit-stands, 6-minute walk, and psoas muscle area to height ratio outperformed commonly used frailty indexes in predicting postesophagectomy mortality and morbidity. The index provides a robust picture of patients\' fitness for surgery beyond the qualitative \"eyeball\" test.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:822-832.e6
Tang A, Ahmad U, Raja S, Rappaport J, ... Blackstone EH, Murthy SC
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:822-832.e6 | PMID: 33451846
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Abstract

Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

Norton EL, Wu X, Kim KM, Fukuhara S, ... Deeb GM, Yang B
Objective
The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.
Methods
From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).
Results
The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).
Conclusions
Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:873-884.e2
Norton EL, Wu X, Kim KM, Fukuhara S, ... Deeb GM, Yang B
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:873-884.e2 | PMID: 33451835
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Abstract

Operative risks of the Ross procedure.

Stelzer P, Mejia J, Varghese R
Background
The risk of the Ross procedure continues to be debated. We sought to determine the immediate outcomes of the Ross procedure in a large consecutive cohort that included patients undergoing reoperative cardiac surgery and/or concomitant cardiac procedures.
Methods
Between March 1987 and September 2019, 702 patients underwent a full root Ross procedure. There were 530 male patients and 172 female patients, with a mean age of 41.6 years. One hundred and one patients had at least one previous sternotomy; 323 patients had concomitant procedures. Patients were stratified into 2 groups: simple and complex. Simple Ross patients were those who had no previous sternotomy and had only minor concomitant procedures performed at the time of their Ross, such as aortoplasty or closure of patent foramen ovale. The complex Ross group included patients with at least one previous sternotomy and/or additional procedures that we deemed complex, such as ascending aortic replacement and mitral valve repair. Complexity and group outcomes were evaluated in consecutive terciles of time.
Results
There were 7 (1%) operative deaths. Morbidity affected 46 other patients (6.6%). The simple Ross group comprised 419 patients (59.7%), with mortality in 3 (0.7%) and morbidity in 20 (4.8%). The complex Ross comprised 283 patients (40.3%), with mortality in 4 (1.4%) and morbidity in 26 (9.2%). Simple Ross cases decreased in volume over time, with complex cases increasing from 34% to 48%.
Conclusions
Excellent results can be achieved with the Ross procedure despite broader indications that include patients with previous sternotomy and with the need for concomitant procedures.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:905-915.e3
Stelzer P, Mejia J, Varghese R
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:905-915.e3 | PMID: 33451826
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Impact:
Abstract

Midterm outcomes of the Potts shunt for pediatric pulmonary hypertension, with comparison to lung transplant.

Lancaster TS, Shahanavaz S, Balzer DT, Sweet SC, Grady RM, Eghtesady P
Objective
For children with severe pulmonary hypertension, addition of Potts shunt to a comprehensive palliation strategy might improve the outcomes afforded by medications and delay lung transplantation.
Methods
A prospective analysis was conducted of all children undergoing Potts shunt (first performed in 2013) or bilateral lung transplant for pulmonary hypertension from 1995 to present.
Results
A total of 23 children underwent Potts shunt (20 surgical, 3 transcatheter), and 31 children underwent lung transplant. All children with Potts shunt had suprasystemic right ventricle pressures despite maximal medical treatment. In the majority of patients, the Potts shunt was performed through a left thoracotomy approach (90%, 18/20), by direct anastomosis (65%, 13/20), and without the use of extracorporeal support (65%, 13/20). Perioperative outcomes after Potts shunt were superior to lung transplant including mechanical ventilation time (1.3 vs 10.2 days, P = .019), median hospital length of stay (9.8 vs 34 days, P = .012), and overall complication rate (35% [7/20] vs 81% [25/31], P = .003). Risk factors for operative mortality after Potts shunt (20%, 4/20; compared with 6%, 2/31 for lung transplant, P = .195) included preoperative extracorporeal membrane oxygenation and significant right ventricle dysfunction. In midterm follow-up (median 1.8, maximum 6.1 years), patients with Potts shunt had durable equalization of right ventricle/left ventricle pressures and improved functional status. There was no significant survival difference in patients with Potts shunt and patients with lung transplant (P = .258).
Conclusions
Potts shunt is an effective palliation for children with suprasystemic pulmonary hypertension that may become part of a strategy to maximize longevity and functional status for these challenging patients.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1139-1148
Lancaster TS, Shahanavaz S, Balzer DT, Sweet SC, Grady RM, Eghtesady P
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1139-1148 | PMID: 33454101
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Impact:
Abstract

Sutureless versus conventional bioprostheses for aortic valve replacement in severe symptomatic aortic valve stenosis.

Fischlein T, Folliguet T, Meuris B, Shrestha ML, ... Lorusso R, Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement Investigators
Objective
Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.
Methods
The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.
Results
At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.
Conclusions
Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:920-932
Fischlein T, Folliguet T, Meuris B, Shrestha ML, ... Lorusso R, Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement Investigators
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:920-932 | PMID: 33478837
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Impact:
Abstract

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest.

Donahoe LL, Nason GJ, Bedard PL, Hansen AR, ... Hamilton RJ, de Perrot M
Objective
Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery.
Methods
A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018.
Results
Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03).
Conclusions
The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:856-868.e1
Donahoe LL, Nason GJ, Bedard PL, Hansen AR, ... Hamilton RJ, de Perrot M
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:856-868.e1 | PMID: 33478834
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Impact:
Abstract

Safety and feasibility of esophagectomy following combined immunotherapy and chemoradiotherapy for esophageal cancer.

Sihag S, Ku GY, Tan KS, Nussenzweig S, ... Jones DR, Molena D
Objectives
We sought to determine the safety and feasibility of esophagectomy after neoadjuvant immunotherapy and chemoradiotherapy in clinical trial patients with locally advanced esophageal cancer.
Methods
We retrospectively identified patients who were treated with neoadjuvant immunotherapy and chemoradiotherapy (n = 25) or chemoradiotherapy alone (n = 143) at our institution between 2017 and 2020. The primary end point was risk of 30-day major complications (Clavien-Dindo classification system grade ≥ 3), which was assessed between groups using a multivariable log-binomial regression model to obtain adjusted relative risk ratios. Secondary end points were interval to surgery, 30-day readmission rate, and 30-day mortality.
Results
All included patients successfully completed neoadjuvant therapy and underwent esophagectomy with negative margins. Age, sex, performance status, clinical stage, histologic subtype, procedure type, and operative approach were similar between groups. Neoadjuvant immunotherapy was not associated with a statistically significantly increased risk of developing a major pulmonary (relative risk, 1.43; 95% confidence interval, 0.53-3.84; P = .5), anastomotic (relative risk, 1.34; 95% confidence interval, 0.45-3.94; P = .6), or other complication (relative risk, 1.29; 95% confidence interval, 0.26-6.28; P = .8). Median (interquartile range) interval to surgery was 54 days (47-61 days) in the immune checkpoint inhibitor group versus 53 days (47-66 days) in the control group (P = .6). Minimally invasive approaches were successful in 72% of cases, with only 1 conversion. Thirty-day mortality and readmission rates were 0% and 17%, respectively, in the immune checkpoint inhibitor group and 1.4% and 13%, respectively, in the control group.
Conclusions
On the basis of our preliminary experience, esophagectomy appears to be safe and feasible following combined neoadjuvant immunotherapy and standard chemoradiotherapy for locally advanced esophageal cancer.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:836-843.e1
Sihag S, Ku GY, Tan KS, Nussenzweig S, ... Jones DR, Molena D
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:836-843.e1 | PMID: 33485662
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Impact:
Abstract

Right ventricular undersizing is associated with increased 1-year mortality.

Kawabori M, Critsinelis AC, Hironaka CE, Chen FY, ... Thayer KL, Couper GS
Objectives
Right heart hemodynamic management is critical, because many post-heart transplantation (HTx) complications are related to right ventricular (RV) failure. However, current guidelines on size and sex matching rely primarily on weight matching, with recent literature using total ventricular mass (TVM), which places less emphasis on the impact of RV mass (RVM) matching. The aim of the present study was to analyze the relationship of RVM matching and survival after HTx.
Methods
We performed the retrospective analysis using the UNOS database of adult HTx performed between January 1997 and December 2017. Previously validated equations were used to calculate TVM and RVM. The percent difference in ventricular mass in the donor and recipient pair was used for the size mismatch. All donor-recipient pairs were divided into 4 RVM groups by their mismatch ratio. We analyzed RVM matching and explored how RVM undersizing impacted outcomes. The primary outcome measure was 1-year survival; secondary outcomes measured included stroke and dialysis within 1 year and functional status.
Results
A total of 38,740 donor-recipient pairs were included in our study. The 4 RVM match groupings were as follows: <0%, 0% to 20%, 20% to 40%, and >40%. Utilization of donors who were older and of female sex resulted in greater RVM undersizing. Survival analysis demonstrated patients with RVM undersizing had worse 1-year survival (P < .001). RVM undersizing was an independent predictor of higher 1-year mortality (hazard ratio, 1.23; 95% confidence interval, 1.11 to 1.34; P < .001). RVM undersizing was also associated with higher rates of dialysis within 1-year of transplantation and poorer postoperative functional status.
Conclusions
RVM undersizing is an independent predictor for worse 1-year survival. Donors who are older and female have lower absolute predicted RVM and may be predisposed to RVM undersizing. RVM-undersized transplantation requires careful risk/benefit considerations.

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

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1048-1059.e3
Kawabori M, Critsinelis AC, Hironaka CE, Chen FY, ... Thayer KL, Couper GS
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1048-1059.e3 | PMID: 33485653
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Impact:
Abstract

High-degree Norwood neoaortic tapering is associated with abnormal flow conduction and elevated flow-mediated energy loss.

Schäfer M, Di Maria MV, Jaggers J, Stone ML, ... Barker AJ, Mitchell MB
Objective
The Norwood neoaortic arch biomechanical properties are abnormal due to reduced vessel wall compliance and abnormal geometry. Others have previously described neoaortic geometric distortion by the degree of diameter reduction (tapering) and associated this with mismatched ventricular-neoaortic coupling, abnormal flow hemodynamic parameters, and worse patient outcome. Our purposes were to investigate the influence of neoaortic tapering (ie, diameter reduction) on flow-mediated viscous energy loss (EL\') in post-Norwood palliated hypoplastic left heart syndrome patients, and correlate flow-geometry with single ventricle power generation.
Methods
Twenty-six palliated hypoplastic left heart syndrome patients underwent comprehensive cardiac evaluation with 4-dimensional-flow magnetic resonance imaging. Patients were grouped into high- (group H, n = 13) and low- (group L, n = 13) degree neoaortic tapering using the median cutoff value of neoaortic diameter variance. EL\' was calculated along standardized segments using 4-dimensional-flow magnetic resonance imaging. Flow-mediated power loss as a percentage of total power generated by the single ventricle was determined.
Results
Group H had a higher prevalence of abnormal recirculating flow in the neoaorta and elevated neoaortic EL\' in the ascending aorta (1.0 vs 0.6 mW; P = .004). Group H EL\' was increased across the entire thoracic aorta (2.6 vs 1.3 mW; P = .002) and accounted for 0.7% of generated ventricular power versus 0.3% in group L (P = .024). EL\' directly correlated with the degree of ascending aortic dilation (R = 0.49; P = .012).
Conclusions
Patients with high degree neoaortic tapering have more perturbed flow through the neoaorta and increased EL\'. Flow-mediated energy loss due to abnormal flow represents irreversibly wasted power generated by the single right ventricle. In patients with high-degree neoaortic tapering, EL\' was more than 2-fold greater than low-degree tapering patients. These data suggest that oversizing the Norwood neoaortic reconstruction should be avoided and that patients with distorted neoaortic geometry may warrant increased surveillance for single-ventricle deterioration.

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

J Thorac Cardiovasc Surg: 03 Feb 2021; epub ahead of print
Schäfer M, Di Maria MV, Jaggers J, Stone ML, ... Barker AJ, Mitchell MB
J Thorac Cardiovasc Surg: 03 Feb 2021; epub ahead of print | PMID: 33653609
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Impact:
Abstract

The impact of pulmonary artery catheter use in cardiac surgery.

Brown JA, Aranda-Michel E, Kilic A, Serna-Gallegos D, ... Thoma FW, Sultan I
Objective
Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring.
Methods
This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups.
Results
Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05).
Conclusions
These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.

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

J Thorac Cardiovasc Surg: 01 Feb 2021; epub ahead of print
Brown JA, Aranda-Michel E, Kilic A, Serna-Gallegos D, ... Thoma FW, Sultan I
J Thorac Cardiovasc Surg: 01 Feb 2021; epub ahead of print | PMID: 33642109
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Impact:
Abstract

Potential role of exosome-based allorecognition pathways involved in lung transplant rejection.

Hwang B, Bryers J, Mulligan MS

Innate and adaptive immunity both contribute to allorecognition mechanisms that drive rejection after lung transplantation. Classic allorecognition pathways have been extensively described, but there continues to be several unanswered questions. Exosome research appears to be a novel and potentially significant area of allorecognition research and could be the missing link that answers some existing questions. This article reviews literature that is associated with allorecognition pathways and the role of exosomes in alloreactivity.

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

J Thorac Cardiovasc Surg: 30 Jan 2021; 161:e129-e134
Hwang B, Bryers J, Mulligan MS
J Thorac Cardiovasc Surg: 30 Jan 2021; 161:e129-e134 | PMID: 33258452
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Impact:
Abstract

Thoracic surgery outcomes for patients with Coronavirus Disease 2019.

Chang SH, Chen D, Paone D, Geraci TC, ... Zervos M, Cerfolio RJ
Objective
As the Coronavirus Disease 2019 pandemic continues, appropriate management of thoracic complications from Coronavirus Disease 2019 needs to be determined. Our objective is to evaluate which complications occurring in patients with Coronavirus Disease 2019 require thoracic surgery and to report the early outcomes.
Methods
This study is a single-institution retrospective case series at New York University Langone Health Manhattan campus evaluating patients with confirmed Coronavirus Disease 2019 infection who were hospitalized and required thoracic surgery from March 13 to July 18, 2020.
Results
From March 13 to August 8, 2020, 1954 patients were admitted to New York University Langone Health for Coronavirus Disease 2019. Of these patients, 13 (0.7%) required thoracic surgery. Two patients (15%) required surgery for complicated pneumothoraces, 5 patients (38%) underwent pneumatocele resection, 1 patient (8%) had an empyema requiring decortication, and 5 patients (38%) developed a hemothorax that required surgery. Three patients (23%) died after surgery, 9 patients (69%) were discharged, and 1 patient (8%) remains in the hospital. No healthcare providers were positive for Coronavirus Disease 2019 after the surgeries.
Conclusions
Given the 77% survival, with a majority of patients already discharged from the hospital, thoracic surgery is feasible for the small percent of patients hospitalized with Coronavirus Disease 2019 who underwent surgery for complex pneumothorax, pneumatocele, empyema, or hemothorax. Our experience also supports the safety of surgical intervention for healthcare providers who operate on patients with Coronavirus Disease 2019.

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

J Thorac Cardiovasc Surg: 29 Jan 2021; epub ahead of print
Chang SH, Chen D, Paone D, Geraci TC, ... Zervos M, Cerfolio RJ
J Thorac Cardiovasc Surg: 29 Jan 2021; epub ahead of print | PMID: 33642100
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Impact:
Abstract

Subnormothermic ex vivo lung perfusion attenuates graft inflammation in a rat transplant model.

Gloria JN, Yerxa J, Kesseli SJ, Davis RP, ... Hartwig MG, Duke Ex Vivo Organ Laboratory
Objective
Ex vivo lung perfusion has emerged as a novel technique to safely preserve lungs before transplantation. Recent studies have demonstrated an accumulation of inflammatory molecules in the perfusate during ex vivo lung perfusion. These proinflammatory molecules, including damage-associated molecular patterns and inflammatory cytokines, may contribute to acute and chronic allograft dysfunction. At present, ex vivo lung perfusion is performed clinically at normothermic temperature (37°C). The effect of lowering temperature to the subnormothermic range during ex vivo lung perfusion has not been reported. In this study, we hypothesized that lower ex vivo lung perfusion temperature will lead to a reduction in allograft inflammation and result in improved post-transplant graft function.
Methods
Lewis rat heart-lung blocs underwent 4 hours of ex vivo lung perfusion in 3 temperature groups: 37°C (MP37), 30°C (MP30), and 25°C (MP25). In the control group, lung grafts were preserved by static cold storage before transplantation. After ex vivo lung perfusion or static cold storage, the left lung was transplanted for 2 hours before the animal was killed. Sera and tissue were collected and analyzed.
Results
There were no differences in partial pressure of arterial oxygenation to fraction of inspired oxygen ratios during 4 hours of ex vivo lung perfusion between temperature groups. Tumor necrosis factor α significantly increased in the MP37 group during ex vivo lung perfusion, whereas this was not seen at lower temperatures. Extracellular DNA and high-mobility group box 1 perfusate concentrations increased significantly during ex vivo lung perfusion in all groups, but the rate of increase was diminished at lower temperature. Two hours post-transplant, there were no significant differences in partial pressure of arterial oxygenation to fraction of inspired oxygen ratios of the lung graft or serum damage-associated molecular pattern levels among groups. On histologic grading after transplantation, greater injury was observed in the MP30 and MP37 groups, but not MP25, when compared with static cold storage.
Conclusions
Subnormothermic ex vivo lung perfusion at 25°C reduces the production of inflammatory mediators during ex vivo lung perfusion and is associated with reduced histologic graft injury after transplantation.

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

J Thorac Cardiovasc Surg: 29 Jan 2021; epub ahead of print
Gloria JN, Yerxa J, Kesseli SJ, Davis RP, ... Hartwig MG, Duke Ex Vivo Organ Laboratory
J Thorac Cardiovasc Surg: 29 Jan 2021; epub ahead of print | PMID: 33640121
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Impact:
Abstract

Association between Z-score for birth weight and postoperative outcomes in neonates and infants with congenital heart disease.

Steurer MA, Peyvandi S, Costello JM, Moon-Grady AJ, ... Tabbutt S, Rajagopal S
Objective
We hypothesized that infants with fetal growth restrictions have increased mortality and morbidity after congenital heart disease surgery.
Methods
The study included patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2016) who underwent cardiac surgery at a corrected gestational age of ≤44 weeks. Patients were classified as severely (birth weight Z-score -4 to -2), moderately (Z-score -2 to -1), and mildly growth restricted (Z-score -1.0 to -0.5) and compared with a reference population (Z-score 0-0.5). Multivariable logistic regression clustering on center was used to evaluate the association of birth weight Z-score with operative mortality and postoperative complications and its interaction with gestational age was assessed.
Results
In 25,244 patients, operative mortality was 8.6% and major complications occurred in 19.4%. Compared with the reference group, the adjusted odds ratio (AOR) of mortality was increased in infants with severe (AOR, 2.4; 95% confidence interval [CI], 2.0-3.0), moderate (AOR, 1.7; 95% CI, 1.4-2.0), and mild growth restriction (AOR, 1.4; 95% CI, 1.2-1.6). The AOR for major postoperative complications was increased for severe (AOR, 1.4; 95% CI, 1.2-1.7) and moderate growth restriction (AOR, 1.2; 95% CI, 1.1-1.4). There was significant interaction between birth weight Z-score and gestational age (P = .007).
Conclusions
Even birth weight Z-scores slightly below average are independent risk factors for mortality and morbidity in infants who undergo cardiac surgery. The strongest association between poor fetal growth and operative mortality exists in early-term infants. These novel findings might account for some of the previously unexplained variation in cardiac surgical outcomes.

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

J Thorac Cardiovasc Surg: 28 Jan 2021; epub ahead of print
Steurer MA, Peyvandi S, Costello JM, Moon-Grady AJ, ... Tabbutt S, Rajagopal S
J Thorac Cardiovasc Surg: 28 Jan 2021; epub ahead of print | PMID: 33640137
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Impact:
Abstract

Prepump autologous blood collection is associated with reduced intraoperative transfusions in aortic surgery with circulatory arrest: A propensity score-matched analysis.

Geube M, Sale S, Bakdash S, Rajeswaran J, ... Blackstone E, Johnston D
Objective
To evaluate the effect of autologous whole blood (AWB) collection on intraoperative/postoperative allogeneic blood transfusion rate in complex aortic surgery with hypothermic circulatory arrest.
Methods
This retrospective study included adults who underwent aortic surgery with hypothermic circulatory arrest at a single institution between 2014 and 2019. Out of 509 cases (414 patients), 110 (22%) received the AWB protocol. We performed propensity-score matching, including 35 preoperative and procedural variables, which resulted in 95 well-matched pairs, to compare outcomes in patients who received AWB protocol versus those who did not. Study outcomes were percentage of patients who received transfusion of allogeneic blood products intraoperatively and postoperatively.
Results
Mean volume of collected autologous blood was 826 ± 263 mL. Intraoperatively, fewer AWB patients received red blood cell concentrate (33% vs 49%; P = .02), plasma (35% vs 62%; P = .0002), platelets (61% vs 81%; P = .003), and cryoprecipitate (43% vs 56%; P = .08) compared with non-AWB patients. During the entire hospital stay, the differences in transfusion rate between the 2 groups were: red blood cells (58% vs 62%; P = .6), plasma (49% vs 66%; P = .01), platelets (72% vs 82%; P = .09), and cryoprecipitate (56% vs 63%; P = .3).
Conclusions
Pre-pump autologous blood collection may reduce the need for intraoperative transfusion of allogenic non-red-cell blood products in patients undergoing complex aortic surgery with hypothermic circulatory arrest. A larger study is needed to clarify the influence of this association on patient outcomes and resource utilization.

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

J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print
Geube M, Sale S, Bakdash S, Rajeswaran J, ... Blackstone E, Johnston D
J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print | PMID: 33610366
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Impact:
Abstract

Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fraction.

Deo SV, Sundaram V, Sahadevan J, Selvaganesan P, ... Kilic A, Cmolik B
Background
Coronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and < 55%).
Methods
We analyzed data on isolated CABG patients from the Veterans Affairs national database (2010-2019). We stratified patients into control (normal LVEF and no heart failure), HFmrEF, and heart failure with reduced LVEF (HFrEF) groups. We compared all-cause mortality and heart failure hospitalization rates between groups with a Cox model and recurrent events analysis, respectively.
Results
In 6533 veterans, HFmrEF and HFrEF was present in 1715 (26.3%) and 566 (8.6%) respectively; the control group had 4252 (65.1%) patients. HFrEF patients were more likely to have diabetes mellitus (59%), insulin therapy (36%), and previous myocardial infarction (31%). Anemia was more prevalent in patients with HFrEF (49%) as was a lower serum albumin (mean, 3.6 mg/dL). Compared with the control group, a higher risk of death was observed in the HFmrEF (hazard ratio [HR], 1.3 [1.2-1.5)] and HFrEF (HR, 1.5 [1.2-1.7]) groups. HFmrEF patients had the higher risk of myocardial infarction (subdistribution HR, 1.2 [1-1.6]; P = .04). Risk of heart failure hospitalization was higher in patients with HFmrEF (HR, 4.1 [3.5-4.7]) and patients with HFrEF (HR, 7.2 [6.2-8.5]).
Conclusions
Heart failure with midrange ejection fraction negatively affects survival after CABG. These patients also experience higher rates myocardial infarction and heart failure hospitalization.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print
Deo SV, Sundaram V, Sahadevan J, Selvaganesan P, ... Kilic A, Cmolik B
J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print | PMID: 33618872
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Impact:
Abstract

Four right ventricle to pulmonary artery conduit types.

Willetts RG, Stickley J, Drury NE, Mehta C, ... Brawn WJ, Botha P
Objective
The most durable valved right ventricle to pulmonary artery conduit for the repair of congenital heart defects in patients of different ages, sizes, and anatomic substrate remains uncertain.
Methods
We performed a retrospective analysis of 4 common right ventricle to pulmonary artery conduits used in a single institution over 30 years, using univariable and multivariable models of time-to-failure to analyse freedom from conduit dysfunction, reintervention, and replacement.
Results
Between 1988 and 2018, 959 right ventricle to pulmonary artery conduits were implanted: 333 aortic homografts, 227 pulmonary homografts, 227 composite porcine valve conduits, and 172 bovine jugular vein conduits. Patients weighed 1.6 to 98.3 kg (median 15.3 kg), and median duration of follow-up was 11.4 years, with 505 (52.2%) conduits developing dysfunction, 165 (17.2%) requiring catheter intervention, and 415 (43.2%) being replaced. Greater patient weight, conduit z-score, type and position, as well as catheter intervention were predictors of freedom from replacement. Multivariable analysis demonstrated inferior durability for smaller composite porcine valve conduits, with excellent durability for larger diameter conduits of the same type. Bovine jugular vein conduit longevity was inferior to that of homografts in all but the smallest patients. Freedom from dysfunction at 8 years was 60.7% for aortic homografts, 72% for pulmonary homografts, 51.2% for composite porcine valve conduits, and 41.3% for bovine jugular vein conduits. Judicious oversizing of the conduit improved conduit durability in all patients, but to the greatest extent in patients weighing 5 to 20 kg.
Conclusions
Pulmonary and aortic homografts had greater durability than xenograft conduits, particularly in patients weighing 5 to 20 kg. Judicious oversizing was the most significant surgeon-modifiable factor affecting conduit longevity.

Copyright © 2021 The American Association for Thoracic Surgery. All rights reserved.

J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print
Willetts RG, Stickley J, Drury NE, Mehta C, ... Brawn WJ, Botha P
J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print | PMID: 33640135
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Impact:
Abstract

Concomitant surgical ablation for atrial fibrillation is associated with increased risk of acute kidney injury but improved late survival.

Bakir NH, Khiabani AJ, MacGregor RM, Kelly MO, ... Helwani MA, Damiano RJ
Background
Acute kidney injury (AKI) after cardiac surgery remains a common complication that has been associated with increased morbidity and mortality. This study implemented Kidney Disease Improving Global Outcomes criteria to evaluate renal outcomes after concomitant surgical ablation for atrial fibrillation.
Methods
Patients with a history of atrial fibrillation who underwent elective cardiac surgery at our institution from 2008 to 2018 were retrospectively reviewed. Those with preoperative renal dysfunction were excluded. Patients were classified as those who underwent concomitant Cox-Maze IV (CMP-IV) (n = 376) or no surgical ablation (n = 498). Nearest neighbor 1:1 propensity matching was conducted on fourteen covariates. AKI was evaluated by mixed effects logistic regression analysis. Long-term survival was evaluated by proportional hazards regression.
Results
Propensity matching yielded 308 patients in each group (n = 616). All preoperative variables were similar between groups. The concomitant CMP-IV group had a greater incidence of AKI: 32% (n = 99) versus 16% (n = 49), P < .001. After accounting for bypass time and nonablation operations on mixed effects analysis, concomitant CMP-IV was associated with increased risk of AKI (odds ratio, 1.89; confidence interval, 1.12-3.18; P = .017). While AKI was associated with decreased late survival (P < .001), patients who received a concomitant CMP-IV maintained superior 7-year survival to patients who received no ablation (P < .001). No patients required permanent dialysis.
Conclusions
Concomitant CMP-IV was independently associated with increased risk of AKI in the acute postoperative period. However, the long-term risks of AKI were offset by the significant survival benefit of CMP-IV. Concerns regarding new-onset renal dysfunction should not prohibit recommendation of this procedure in appropriate patients.

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

J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print
Bakir NH, Khiabani AJ, MacGregor RM, Kelly MO, ... Helwani MA, Damiano RJ
J Thorac Cardiovasc Surg: 22 Jan 2021; epub ahead of print | PMID: 33653608
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Impact:
Abstract

Protective effect of necrosulfonamide on rat pulmonary ischemia-reperfusion injury via inhibition of necroptosis.

Ueda S, Chen-Yoshikawa TF, Tanaka S, Yamada Y, ... Ohsumi A, Date H
Background
Necroptosis plays an important role in cell death during pulmonary ischemia-reperfusion injury (IRI). We hypothesized that therapy with necrosulfonamide (NSA), a mixed-lineage kinase domain-like protein inhibitor, would attenuate lung IRI.
Methods
Rats were assigned at random into the sham operation group (n = 6), vehicle group (n = 8), or NSA group (n = 8). In the NSA and vehicle groups, the animals were heparinized and underwent left thoracotomy, and the left hilum was clamped for 90 minutes, followed by reperfusion for 120 minutes. NSA (0.5 mg/body) and a solvent were administered i.p. in the NSA group and the vehicle group, respectively. The sham group underwent 210 minutes of perfusion without ischemia. After reperfusion, arterial blood gas analysis, physiologic data, lung wet-to-dry weight ratio, histologic changes, and cytokine levels were assessed. Fluorescence double immunostaining was performed to evaluate necroptosis and apoptosis.
Results
Arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) was better, dynamic compliance was higher, and mean airway pressure and lung edema were lower in the NSA group compared with the vehicle group. Moreover, in the NSA group, lung injury was significantly alleviated, and the mean number of necroptotic cells (55.3 ± 4.06 vs 78.2 ± 6.87; P = .024), but not of apoptotic cells (P = .084), was significantly reduced compared with the vehicle group. Interleukin (IL)-1β and IL-6 levels were significantly lower with NSA administration.
Conclusions
In a rat model, our results suggest that NSA may have a potential protective role in lung IRI through the inhibition of necroptosis.

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

J Thorac Cardiovasc Surg: 21 Jan 2021; epub ahead of print
Ueda S, Chen-Yoshikawa TF, Tanaka S, Yamada Y, ... Ohsumi A, Date H
J Thorac Cardiovasc Surg: 21 Jan 2021; epub ahead of print | PMID: 33612303
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Impact:
Abstract

The impact of additional antegrade pulmonary blood flow at bidirectional Glenn shunt on long-term outcomes.

Baek JS, Park CS, Choi ES, Yun TJ, ... Yu JJ, Kim YH
Objectives
We investigated the impact of additional antegrade pulmonary blood flow on the long-term outcomes after bidirectional Glenn shunt.
Methods
From 2001 to 2015, 279 patients underwent bidirectional Glenn shunt as an interim palliation for a functionally single ventricle. After excluding patients with a previous Kawashima or Norwood operation, 202 patients with preexisting antegrade pulmonary blood flow before bidirectional Glenn shunt were included in this study. Antegrade pulmonary blood flow was eliminated in 110 patients (no antegrade pulmonary blood flow group) and maintained in 92 patients (antegrade pulmonary blood flow group). The impact of antegrade pulmonary blood flow at bidirectional Glenn shunt on long-term outcome was analyzed using inverse probability of treatment weighting.
Results
Median age and body weight at bidirectional Glenn shunt were 8 months and 7.8 kg, respectively. Prolonged chest tube drainage or readmission for effusion after bidirectional Glenn shunt was more frequent in the antegrade pulmonary blood flow group (odds ratio, 3.067; 95% confidence interval, 1.036-9.073; P = .043). In the no antegrade pulmonary blood flow group, B-type natriuretic peptide level was decreased further until the Fontan operation (P = .012). In the no antegrade pulmonary blood flow group, oxygen saturation was lower just after bidirectional Glenn shunt, although it was increased further until Fontan operation (P < .001), despite still lower oxygen saturation before Fontan operation compared with antegrade pulmonary blood flow group (P < .001). The McGoon ratio was decreased in both groups without intergroup difference, although the McGoon ratio before Fontan operation was higher in the antegrade pulmonary blood flow group (2.3 ± 0.4 vs 2.1 ± 0.4, P = .008). Overall transplant-free survival was worse in the antegrade pulmonary blood flow group (hazard ratio, 2.37; confidence interval, 1.089-5.152; P = .030).
Conclusions
Maintaining antegrade pulmonary blood flow at bidirectional Glenn shunt was beneficial for higher oxygen saturation and larger pulmonary artery size before Fontan operation. However, it was unfavorable for overall transplant-free survival with a sustained higher risk of death or transplant until the elimination of antegrade pulmonary blood flow.

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

J Thorac Cardiovasc Surg: 21 Jan 2021; epub ahead of print
Baek JS, Park CS, Choi ES, Yun TJ, ... Yu JJ, Kim YH
J Thorac Cardiovasc Surg: 21 Jan 2021; epub ahead of print | PMID: 33612299
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Abstract

Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection.

Spinelli D, Weaver FA, Azizzadeh A, Magee GA, ... Gable DR, Trimarchi S
Objective
The study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections.
Methods
Patients from WL Gore\'s Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed.
Results
Of 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696).
Conclusions
In the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.

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

J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print
Spinelli D, Weaver FA, Azizzadeh A, Magee GA, ... Gable DR, Trimarchi S
J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print | PMID: 33612294
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Impact:
Abstract

Fate of moderate aortic regurgitation after cardiac surgery.

Ward A, Malaisrie SC, Andrei AC, Bonow RO, ... Kruse J, McCarthy PM
Objective
To determine the prevalence of concomitant aortic regurgitation (AR) in cardiac surgery and the outcomes of treatment options.
Methods
Between April 2004 and June 2018, 3289 patients underwent coronary artery bypass, mitral valve, or aortic aneurysm surgery without aortic stenosis. AR was graded none/trivial (score = 0), mild (score = 1+), or moderate (score = 2+). Patients with untreated 2+ AR were compared with those with 0 or 1+ AR, and to those with 2+ AR who had aortic valve surgery. Thirty-day and late survival, echocardiography, and clinical outcomes were compared using propensity score matching.
Results
One hundred thirty-eight patients (4.2%) had 2+ AR; and 45 (33%) received aortic valve repair (n = 9) or replacement (n = 36) in the treated group and were compared with 2765 untreated patients with 0 AR and 386 patients with 1+ AR. Valve surgery was more common with anatomic leaflet abnormalities: bicuspid aortic valve (9% vs 0%; P < .01), rheumatic valve disease (16% vs 3%; P < .01), and calcification (47% vs 27%; P = .021). In unadjusted analysis, lower preoperative AR grade was associated with increased 10-year survival (P < .001). At year 10, progression to more-than-moderate AR among moderate AR patients was 2.6% and late intervention rate was 3.1%. In the untreated 2+ AR group, on last follow-up echocardiogram, 58% had improvement in AR, 41% remained 2+, and only 1% progressed to severe AR.
Conclusions
Aortic valve surgery in select patients with concomitant moderate AR can be added with minimal added risk, but untreated AR does not influence long-term survival after cardiac surgery and rarely required late intervention.

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

J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print
Ward A, Malaisrie SC, Andrei AC, Bonow RO, ... Kruse J, McCarthy PM
J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print | PMID: 33610367
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Impact:
Abstract

The American College of Surgeons Surgical Risk Calculator performs well for pulmonary resection: A validation study.

Chudgar N, Yan S, Hsu M, Tan KS, ... Rocco G, Isbell JM
Objective
The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP SRC) was developed to estimate the risk of postoperative morbidity and mortality within 30 days of an operation. We sought to externally evaluate the performance of the NSQIP SRC for patients undergoing pulmonary resection.
Methods
Patients undergoing pulmonary resection at our center between January 2016 and December 2018 were included. Using data from our institution\'s prospectively maintained Society of Thoracic Surgeons General Thoracic Database, we identified 2514 patients. We entered requisite patient demographic information, preoperative risk factors, and procedural details into the online calculator. Predicted performance of the calculator versus observed outcomes was assessed by discrimination (concordance index [C-index]) and calibration.
Results
The observed and predicted probabilities of any complication were 8.3% and 9.9%, respectively, and of serious complications were 7.4% and 9.2%, respectively. Observed and predicted 30-day mortality were 0.5% and 0.9%, respectively. The C-index for readmission was 0.644; the C-indices corresponding to all other outcomes in the NSQIP SRC ranged from 0.703 to 0.821. Calibration curves indicated excellent calibration for all binary end points, with the exception of renal failure (predicted underestimated observed probabilities), discharge to a nursing or rehabilitation facility (overestimated), and sepsis (overestimated). Correlation between predicted and observed length of stay was moderate (Spearman coefficient, 0.562), and calibration was good.
Conclusions
Except for readmission, renal failure, discharge to a location other than home, and sepsis, the NSQIP SRC can be used to reasonably predict postoperative complications in patients undergoing pulmonary resection.

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

J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print
Chudgar N, Yan S, Hsu M, Tan KS, ... Rocco G, Isbell JM
J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print | PMID: 33610360
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Impact:
Abstract

Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy?

Lentz Carvalho J, Schaff HV, Nishimura RA, Ommen SR, ... Newman DB, Dearani JA
Objectives
Elongation of mitral valve leaflets is a phenotypic feature of hypertrophic cardiomyopathy, and some surgeons advocate plication of the anterior leaflet at the time of septal myectomy. The present study investigates mitral valve leaflet length and outcomes of patients undergoing septal myectomy for obstructive hypertrophic cardiomyopathy.
Methods
We reviewed the records and echocardiograms of 564 patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy between February 2015 and April 2018. Extended septal myectomy without plication of the anterior leaflet was the standard procedure. From intraoperative prebypass transesophageal echocardiograms, we measured anterior and posterior mitral valve leaflets and their coaptation length. For comparison, we performed these mitral valve leaflet measurements in 90 patients who underwent isolated coronary artery bypass grafting and 92 patients undergoing aortic valve replacement in the same period. Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, we assessed left ventricular outflow tract gradient relief and 1-year survival in relation to leaflet length.
Results
Median patient age (interquartile range) was 60.3 (50.2-67.7) years, and 54.1% were male. Concomitant mitral valve repair was performed in 36 patients (6.4%), and mitral valve replacement was performed in 8 patients (1.4%), primarily for intrinsic mitral valve disease. Patients in the hypertrophic cardiomyopathy cohort had significantly longer mitral valve leaflet measurements compared with patients undergoing coronary artery bypass grafting or aortic valve replacement (P < .001 for all 3 measurements). Preoperative resting left ventricular outflow tract gradients were not related to leaflet length (<30 mm, median 49 [21, 81.5] mm Hg vs ≥30 mm, 50.5 [21, 77] mm Hg; P = .76). Further, gradient reduction after myectomy was not related to leaflet length; patients with less than 30 mm anterior leaflet length had a median gradient reduction of 33 (69, 6) mm Hg compared with 36.5 (62, 6) mm Hg for patients with leaflet length 30 mm or more (P = .36). Anterior mitral valve leaflet length was not associated with increased 1-year mortality (P = .758).
Conclusions
Our study confirms previous findings that patients with hypertrophic cardiomyopathy have slight (5 mm) elongation of mitral valve leaflets. In contrast to other reports, increased anterior mitral valve leaflet length was not associated with higher left ventricular outflow tract gradients. Importantly, we found no significant relationship between anterior mitral valve leaflet length and postoperative left ventricular outflow tract resting gradients or gradient relief. Thus, in the absence of intrinsic mitral valve disease, transaortic septal myectomy with focus on extending the excision beyond the point of septal contact is sufficient for almost all patients.

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

J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print
Lentz Carvalho J, Schaff HV, Nishimura RA, Ommen SR, ... Newman DB, Dearani JA
J Thorac Cardiovasc Surg: 20 Jan 2021; epub ahead of print | PMID: 33632527
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Impact:
Abstract

Midterm results of transventricular mitral valve repair: Single-center experience.

Budra M, Janušauskas V, Drąsutienė A, Zorinas A, ... Ručinskas K, NeoChord Research Group
Objective
The study objective was to evaluate the midterm outcomes of transventricular mitral valve repair and its association with the initial anatomy of the mitral valve.
Methods
This nonrandomized observational study included 88 patients (mean age, 60 years; 69% were men) who underwent transventricular mitral valve repair for severe degenerative mitral regurgitation between 2011 and 2017. Mitral valve function was assessed by echocardiography at 1 and 6 months and annually after the procedure. According to the location of mitral valve pathology, all patients were stratified into 4 anatomic types (A, B, C, and D). Results were assessed using Kaplan-Meier method, mixed-effects continuation ratio model, and multivariable Cox regression.
Results
Median follow-up of 42 months (interquartile range, 27-55) was complete for 83 patients (94.3%). There were 3 late deaths: 2 cardiac and 1 noncardiac. Recurrent mitral regurgitation greater than 2+ was observed in 29 patients (33%), and 18 patients (20.5%) underwent repeat surgery. Device success was 82% in type A at 6 months and thereafter; 87%, 85%, and 75% at 6, 12, and 36 months in type B, respectively; and 53% at 1 month and 20% at 24 months in type C. Probability of postoperative mitral regurgitation progression was higher in patients with greater preoperative left ventricular end-diastolic diameter, type B pathology, and type C pathology (P < .05). Risk factors of mitral regurgitation recurrence included increased left ventricle size (hazard ratio, 1.11; 95% confidence interval, 1.04-1.20; P = .001) and type C pathology (hazard ratio, 5.99; 95% confidence interval, 1.87-19.21; P = .003).
Conclusions
Initial acceptable mitral regurgitation reduction after transventricular mitral valve repair of isolated P2 prolapse was possible but found durable in only 82% at 3 years. Higher risk of mitral regurgitation recurrence occurred with complex degenerative pathology.

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

J Thorac Cardiovasc Surg: 19 Jan 2021; epub ahead of print
Budra M, Janušauskas V, Drąsutienė A, Zorinas A, ... Ručinskas K, NeoChord Research Group
J Thorac Cardiovasc Surg: 19 Jan 2021; epub ahead of print | PMID: 33612306
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Impact:
Abstract

The long-term fate of ascending aorta aneurysm after wrapping versus replacement.

Kim HH, Lee S, Lee SH, Youn YN, Yoo KJ, Joo HC
Objective
The study objective was to examine the long-term fate of aortic diameter expansion at 4 cardiac regions (annulus, sinus, ascending aorta, and proximal arch) after wrapping or replacement during aortic valve surgery of the moderately dilated ascending aorta.
Methods
From January 1995 to December 2018, 964 consecutive patients who underwent aortic valve replacement at our institution were reviewed. Of them, 204 (mean age, 60.7 ± 7.4 years) underwent ascending aorta wrapping (n = 96) or replacement (n = 108) for a moderately dilated ascending aorta (40 to 55 mm). The overall fate of the aortic diameter was analyzed with a linear mixed-effect model. The median follow-up duration was 7.1 years.
Results
After propensity score matching, the baseline maximal ascending aortic diameter median value was 47.3 ± 3.1 mm and 49.4 ± 13.5 mm in the wrapping and replacement groups, respectively. The annulus, sinus, and ascending aorta did not redilate in either group. The proximal aortic arch diameter significantly increased over time (0.343 mm/year; P = .006) in the wrapping group but not in the replacement group (0.066 mm/year; P = .649). Multivariable competing risk analysis identified the initial ascending aorta diameter at the wrapping procedure as an independent risk factor of proximal arch redilation (0.071 ± 0.037, P < .001). The cutoff value was an initial ascending aorta diameter of 47.2 mm for the prediction proximal arch redilation (area under the curve, 0.703; P = .014).
Conclusions
Aortic wrapping and replacement may be long-term durable treatment options in patients with a moderately enlarged ascending aorta. We suggest careful evaluation of redilation in the proximal arch after an aorta wrapping procedure.

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

J Thorac Cardiovasc Surg: 18 Jan 2021; epub ahead of print
Kim HH, Lee S, Lee SH, Youn YN, Yoo KJ, Joo HC
J Thorac Cardiovasc Surg: 18 Jan 2021; epub ahead of print | PMID: 33597100
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Impact:
Abstract

Midterm outcomes with a sutureless aortic bioprosthesis in a prospective multicenter cohort study.

Fischlein T, Meuris B, Folliguet T, Hakim-Meibodi K, ... Haverich A, CAVALIER Trial Investigators
Objective
The objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve.
Methods
Between 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years.
Results
The mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years.
Conclusions
This series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.

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

J Thorac Cardiovasc Surg: 12 Jan 2021; epub ahead of print
Fischlein T, Meuris B, Folliguet T, Hakim-Meibodi K, ... Haverich A, CAVALIER Trial Investigators
J Thorac Cardiovasc Surg: 12 Jan 2021; epub ahead of print | PMID: 33597099
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Impact:
Abstract

A tailored strategy for repair of acute type A aortic dissection.

Lau C, Robinson NB, Farrington WJ, Rahouma M, ... Gaudino M, Girardi LN
Objective
Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.
Methods
We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis.
Results
From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01).
Conclusions
A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.

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

J Thorac Cardiovasc Surg: 11 Jan 2021; epub ahead of print
Lau C, Robinson NB, Farrington WJ, Rahouma M, ... Gaudino M, Girardi LN
J Thorac Cardiovasc Surg: 11 Jan 2021; epub ahead of print | PMID: 33558116
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Impact:
Abstract

Impact of donor blood type on outcomes after prolonged allograft ischemic times.

Tang PC, Haft JW, Lei I, Wang Z, ... Aaronson KD, Pagani FD
Objective
The study objective was to determine the influence of allograft ischemic time on heart transplant outcomes among ABO donor organ types given limited prior reports of its survival impact.
Methods
We identified 32,454 heart transplants (2000-2016) from the United Network for Organ Sharing database. Continuous and categoric variables were analyzed by parametric and nonparametric testing. Survival was determined using log-rank or Cox regression tests. Propensity matching adjusted for preoperative variables.
Results
By comparing allograft ischemic time less than 4 hours (n = 6579) with 4 hours or more (n = 25,875), the hazard ratios for death at 15 years after prolonged ischemic time (≥4 hours) for blood types O, A, B, and AB were 1.106 (P < .001), 1.062 (P < .001), 1.059 (P = .062), and 1.114 (P = .221), respectively. Unadjusted data demonstrated higher mortality for transplantation of O versus non-O donor hearts for ischemic time 4 hours or more (hazard ratio, 1.164; P < .001). After propensity matching, O donor hearts continued to have worse survival if preserved for 4 hours or more (hazard ratio, 1.137, P = .008), but not if ischemic time was less than 4 hours (hazard ratio, 1.042, P = .113). In a matched group with 4 hours or more of ischemic time, patients receiving O donor organs were more likely to experience death from primary graft dysfunction (2.5% vs 1.7%, P = .052) and chronic allograft rejection (1.9% vs 1.1%, P = .021). No difference in death from primary graft dysfunction or chronic allograft rejection was seen with less than 4 hours of ischemic time (P > .150).
Conclusions
Compared with non-O donor hearts, transplantation with O donor hearts with ischemic time 4 hours or more leads to worse survival, with higher rates of primary graft dysfunction and chronic rejection. Caution should be practiced when considering donor hearts with the O blood type when anticipating extended cold ischemic times.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 11 Jan 2021; epub ahead of print
Tang PC, Haft JW, Lei I, Wang Z, ... Aaronson KD, Pagani FD
J Thorac Cardiovasc Surg: 11 Jan 2021; epub ahead of print | PMID: 33558115
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Impact:
Abstract

Resident education in congenital heart surgery does not compromise outcomes.

Cleveland JD, Bowdish ME, Mack WJ, Kim RW, ... Wells WJ, Starnes VA
Objective
Most of all congenital cardiac surgical programs participate in public outcomes reporting. The primary end point is transparency. In this era, academic programs with surgical residents face the challenge of producing outstanding results while allowing residents to learn by doing. We sought to understand the effect of education on our surgical outcomes.
Methods
We collected data for all American Board of Thoracic Surgery index cases done at our institution over a 10-year period. We identified 3406 cases and categorized them into 2 groups according to primary surgeon: attending (2269) versus resident (1137). In a multivariable logistic regression model we examined the effect of operating surgeon on in-hospital mortality, major morbidity, and length of stay. We used propensity score matching subsequently to balance differences between cohorts, and multivariable logistic regression was repeated.
Results
Using the entire cohort, multivariable logistic regression model adjusted for age, sex, weight, lack of preoperative comorbidity, presence of preoperative respiratory failure, The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery category, and need for deep hypothermic circulatory arrest, showed a higher odds of survival in the resident cohort (odds ratio, 1.484; 95% confidence interval, 0.998-2.206; P = .05). Propensity score matching identified 1137 pairs of attending and resident cases with well-balanced preoperative variables. Logistic regression modeling using the matched cohort showed equivalent 30-day mortality, 30-day major morbidity, and length of stay.
Conclusions
There was no difference in mortality, major morbidity, or length of stay when similar cases were compared that were operated on by attendings versus those by a resident. Effectively educating congenital heart surgeons without compromising an operation\'s quality requires thoughtful approach, including case selection and graded responsibility.

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

J Thorac Cardiovasc Surg: 10 Jan 2021; epub ahead of print
Cleveland JD, Bowdish ME, Mack WJ, Kim RW, ... Wells WJ, Starnes VA
J Thorac Cardiovasc Surg: 10 Jan 2021; epub ahead of print | PMID: 33581904
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Impact:
Abstract

Factors associated with esophageal motility improvement after bilateral lung transplant in patients with an aperistaltic esophagus.

Giulini L, Mittal SK, Masuda T, Razia D, ... Smith MA, Bremner RM
Objectives
We reported that esophageal peristalsis can improve after lung transplant (LTx), even in patients with pretransplant esophageal aperistalsis. This improvement was associated with better outcomes. We analyzed preoperative factors and sought to predict persistent aperistalsis or motility improvement in patients with pre-LTx esophageal aperistalsis.
Methods
Patients with esophageal aperistalsis who underwent LTx between January 2013 and December 2016 were included. Preoperative barium esophagrams were blinded and re-examined; subjective scores were assigned to motility and dilation patterns. Postoperative high-resolution manometry was used to divide patients into 2 groups: persistent esophageal aperistalsis (PEA) or improved esophageal peristalsis (IEP).
Results
We identified 29 patients: 20 with restrictive lung disease, 7 with obstructive lung disease, and 2 with pulmonary arterial hypertension. Post-LTx, 10 patients had PEA and 19 had IEP (mean age, 53.3 ± 6.6 years and 61.2 ± 10.6 years, respectively; P = .04). All 9 patients (100%) with obstructive lung disease or pulmonary arterial hypertension but only 10 of 20 patients (50%) with restrictive lung disease had IEP post-LTx (P = .01). All 4 patients with scleroderma had PEA. Nearly absent contractility on preoperative esophagrams was more prevalent in the PEA group than in the IEP group (100% vs 58.8%; P = .06). No further differences were observed between the groups.
Conclusions
Patients with esophageal aperistalsis and obstructive lung disease or pulmonary arterial hypertension, but not patients with restrictive lung disease and scleroderma, are likely to have IEP post-LTx. Additional studies may determine whether subjective esophagram assessment can help predict IEP post-LTx in patients with restrictive lung disease without scleroderma.

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

J Thorac Cardiovasc Surg: 08 Jan 2021; epub ahead of print
Giulini L, Mittal SK, Masuda T, Razia D, ... Smith MA, Bremner RM
J Thorac Cardiovasc Surg: 08 Jan 2021; epub ahead of print | PMID: 33568319
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Impact:
Abstract

Experience with a standardized protocol to predict successful explantation of left ventricular assist devices.

Hrytsyna Y, Kneissler S, Kaufmann F, Müller M, ... Potapov E, Knierim J
Objective
Patients with a continuous-flow left ventricular assist device may show recovery of myocardial function with unloading. Identifying candidates for and predicting clinical and hemodynamic stability after left ventricular assist device explantation remain challenging.
Methods
Retrospective analysis of patients who underwent evaluation for left ventricular assist device explantation following a standardized protocol from January 2016 to March 2020. Patients who met screening criteria underwent echocardiography under \"baseline,\" \"minimal net flow,\" and \"pump stop\" conditions. If the protocol criteria were met, right heart catheterization with left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter were performed. In patients with pulmonary capillary wedge pressure less than 16 mm Hg, explantation was performed under \"pump stop\" conditions.
Results
A total of 544 patients were screened. Of these, 57 (10.5%) underwent a total of 73 echocardiography under \"baseline\" \"minimal net flow\" and \"pump stop\" conditions and 46 underwent left ventricular assist device stoppage and occlusion of the outflow graft with balloon catheter maneuvers. Complications during the procedure were rare. Ultimately, 21 patients (3.9%) underwent explantation. The left ventricular ejection fraction at baseline was 55.5% ± 6.5%. The mean pulmonary capillary wedge pressure was 8.1 ± 2.6 mm Hg and increased to 10.7 ± 2.9 mm Hg under left ventricular assist device stoppage and occlusion of the outflow graft with a balloon catheter. A nonischemic cause of cardiomyopathy was more likely to be found in patients who underwent explantation (20/21 patients [95%], P = .020). The survival 1 year after explantation was 95.2%, with 1 death occurring 222 days after left ventricular assist device explantation. At follow-up (median 24.9 months [interquartile range, 16.4-43.1 months]), patients were in New York Heart Association class 1 (61.9%), 2 (28.6%), and 3 (9.5%).
Conclusions
Our 4-year experience with a standardized protocol for left ventricular assist device explantation showed a low rate of adverse events. If all criteria are met, explantation can be performed safely and with an excellent survival and functional class.

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

J Thorac Cardiovasc Surg: 08 Jan 2021; epub ahead of print
Hrytsyna Y, Kneissler S, Kaufmann F, Müller M, ... Potapov E, Knierim J
J Thorac Cardiovasc Surg: 08 Jan 2021; epub ahead of print | PMID: 33581897
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Impact:
Abstract

Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy.

Farsky PS, White J, Al-Khalidi HR, Sueta CA, ... O\'Connor CM, Working Group and Surgical Treatment for IsChemic Heart failure Trial Investigators
Objectives
Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy.
Methods
The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug.
Results
At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation.
Conclusions
Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.

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

J Thorac Cardiovasc Surg: 06 Jan 2021; epub ahead of print
Farsky PS, White J, Al-Khalidi HR, Sueta CA, ... O'Connor CM, Working Group and Surgical Treatment for IsChemic Heart failure Trial Investigators
J Thorac Cardiovasc Surg: 06 Jan 2021; epub ahead of print | PMID: 33610365
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Impact:
Abstract

Outcomes in anomalous aortic origin of a coronary artery after surgical reimplantation.

Bonilla-Ramirez C, Molossi S, Sachdeva S, Reaves-O\'Neal D, ... McKenzie ED, Binsalamah ZM
Objective
Anomalous aortic origin of a coronary artery (AAOCA) can be associated with myocardial ischemia and sudden cardiac arrest. We compared outcomes data of patients who underwent transection and reimplantation (TAR) and patients who underwent an unroofing.
Methods
Patients who presented to the Coronary Artery Anomalies Program were evaluated and managed following a standardized approach. Anatomy was determined using computed tomography angiography, myocardial perfusion using advanced stress imaging, and surgical intervention according to anatomic features.
Results
Sixty-one patients underwent surgical repair of AAOCA between 2012 and 2019: 16 (26%) patients underwent TAR of the anomalous coronary without an aortic button and 45 (74%) patients underwent coronary unroofing. Compared with patients who underwent an unroofing, patients who underwent TAR had similar intramural length (5 mm with interquartile range of 4-7.7 vs 6 mm with interquartile range of 5-7; P = .6). One patient with an anomalous right coronary underwent coronary artery bypass grafting after TAR because of persistent postoperative ischemic changes. One patient with unroofing of an anomalous left coronary artery presented with recurrent aborted sudden cardiac death and underwent subsequent TAR, without further events. At last follow-up, 15 of 16 patients (94%) who underwent TAR and 42 of 45 (93%) patients who underwent an unroofing were released to unrestricted exercise activities.
Conclusions
Coronary artery TAR is a useful surgical alternative for AAOCA when there is a course below the commissure, when unroofing does not relocate the ostium to the appropriate sinus, or when unroofing results in compression by the intercoronary pillar.

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

J Thorac Cardiovasc Surg: 04 Jan 2021; epub ahead of print
Bonilla-Ramirez C, Molossi S, Sachdeva S, Reaves-O'Neal D, ... McKenzie ED, Binsalamah ZM
J Thorac Cardiovasc Surg: 04 Jan 2021; epub ahead of print | PMID: 33541731
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Impact:
Abstract

Impact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery.

Cho JS, Shim JK, Kim KS, Lee S, Kwak YL
Objective
Malnutrition is a well-recognized risk factor for poor prognosis and mortality. We investigated whether preoperative malnutrition diagnosed with objective nutritional scores affects 1-year mortality in patients undergoing valvular heart surgery.
Methods
In this retrospective cohort observational study, we evaluated the association among the Controlling Nutritional Status score, Prognostic Nutritional Index, and Geriatric Nutritional Risk Index with 1-year mortality in 1927 patients undergoing valvular heart surgery. We identified factors for mortality using multivariable Cox proportional hazard analysis and investigated the utility of nutritional scores for risk stratification.
Results
Malnutrition, as identified by a high Controlling Nutritional Status score and low Prognostic Nutritional Index and Geriatric Nutritional Risk Index, was significantly associated with higher 1-year mortality. Kaplan-Meier survival curve showed that mortality significantly increased as the severity of malnutrition increased (log-rank test, P < .001). The predicted discrimination (C-index) was 0.79 with the Controlling Nutritional Status score, 0.77 with the Prognostic Nutritional Index, and 0.73 with the Geriatric Nutritional Risk Index. Each nutritional index (Controlling Nutritional Status; hazard ratio, 1.31, 95% confidence interval, 1.21-1.42, P < .001), the European System for Cardiac Operative Risk Evaluation II (hazard ratio, 1.07, 95% confidence interval, 1.04-1.09, P < .001), and chronic kidney disease (hazard ratio, 2.26, 95% confidence interval, 1.31-3.90, P = .003) were independent risk factors for mortality. The Controlling Nutritional Status score added to the European System for Cardiac Operative Risk Evaluation II significantly increased the predictive discrimination ability for mortality (C-index 0.82, 95% confidence interval, 0.78-0.87, P = .014) compared with the Controlling Nutritional Status or European System for Cardiac Operative Risk Evaluation II alone.
Conclusions
Preoperative malnutrition as assessed by objective nutritional scores was associated with 1-year mortality after valvular heart surgery. The Controlling Nutritional Status score had the highest predictive ability and, when added to the European System for Cardiac Operative Risk Evaluation II, provided more accurate risk stratification.

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

J Thorac Cardiovasc Surg: 04 Jan 2021; epub ahead of print
Cho JS, Shim JK, Kim KS, Lee S, Kwak YL
J Thorac Cardiovasc Surg: 04 Jan 2021; epub ahead of print | PMID: 33551075
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Impact:
Abstract

Long-term outcomes of warfarin versus aspirin after Fontan surgery.

Attard C, Monagle PT, d\'Udekem Y, Mackay MT, ... Ignjatovic V, ANZ Fontan Registry Research group
Objectives
Because of the nature of the Fontan physiology, patients are at an increased risk of thromboembolic complications. As such, warfarin or aspirin is generally prescribed lifelong for thromboprophylaxis. This study aimed to compare long-term rates of cerebrovascular injury, thrombosis, bleeding, bone mineral density, and quality of life in people living with Fontan circulation receiving warfarin compared with aspirin.
Methods
This was a multicenter study of a selected cohort from the Australia and New Zealand Fontan population. Participants underwent cerebral magnetic resonance imaging to detect the presence of cerebrovascular injury (n = 84) and dual-energy X-ray absorptiometry to assess bone mineral density (n = 120). Bleeding (n = 100) and quality of life (n = 90) were assessed using validated questionnaires: Warfarin and Aspirin Bleeding assessment tool and Pediatric Quality of Life Inventory, respectively.
Results
Stroke was detected in 33 participants (39%), with only 7 (6%) being clinically symptomatic. There was no association between stroke and Fontan type or thromboprophylaxis type. Microhemorrhage and white matter injury were detected in most participants (96% and 86%, respectively), regardless of thromboprophylaxis type. Bleeding rates were high in both groups; however, bleeding was more frequent in the warfarin group. Bone mineral density was reduced in our cohort compared with the general population; however, this was further attenuated in the warfarin group. Quality of life was similar between the warfarin and aspirin groups. Home international normalized ratio monitoring was associated with better quality of life scores in the warfarin group.
Conclusions
Cerebrovascular injury is a frequent occurrence in the Australia and New Zealand Fontan population regardless of thromboprophylaxis type. No benefit of long-term warfarin prophylaxis could be demonstrated over aspirin; however, consideration must be given to important clinical features such as cardiac function and lung function. Furthermore, the association of reduced bone health in children receiving warfarin warrants further mechanistic studies.

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

J Thorac Cardiovasc Surg: 04 Jan 2021; epub ahead of print
Attard C, Monagle PT, d'Udekem Y, Mackay MT, ... Ignjatovic V, ANZ Fontan Registry Research group
J Thorac Cardiovasc Surg: 04 Jan 2021; epub ahead of print | PMID: 33563422
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Impact:
Abstract

Atrial functional versus ventricular functional mitral regurgitation: Prognostic implications.

Hirji SA, Cote CL, Javadikasgari H, Malarczyk A, McGurk S, Kaneko T
Background
Atrial functional mitral regurgitation (FMR) occurs because of left atrial dilatation or atrial fibrillation in heart failure with preserved left ventricular (LV) function, contrary to ventricular FMR, which occurs because of LV dysfunction. Despite pathophysiological differences, current guidelines do not discriminate between these 2 entities.
Methods
From January 2002 to March 2019, all adult patients with ≥3+ mitral regurgitation who underwent mitral valve repair or replacement were identified. Postoperative outcomes and midterm time-to-event rates (survival and reoperation) were compared.
Results
Overall, 94 atrial FMR (mean age, 67.6 years) and 84 ventricular FMR (mean age, 64 years) patients met inclusion criteria. Differences in baseline cardiac morphology and function of the atrial FMR and ventricular FMR patients were as follows: concomitant atrial fibrillation (37.2% vs 14.3%), heart failure (42.6% vs 63.1%), LV ejection fraction (60% vs 37%), at least moderate LV dilation (4.8% vs 40.6%), and moderate/severe right heart dysfunction (15.2% vs 5.1%), respectively. Operative mortality was 0% in the atrial FMR versus 1.2% in the ventricular FMR cohort. Actuarial estimates of survival and freedom from reoperation at 5 and 10 years was significantly higher in the atrial FMR cohort versus the ventricular FMR cohort. Ventricular FMR also remained a significant predictor of midterm mortality in our risk-adjusted analysis (adjusted hazard ratio for ventricular FMR, 1.8; 95% confidence interval, 1.001-3.26).
Conclusions
There are important differences in baseline characteristics in terms of cardiac morphology and function among atrial FMR and ventricular FMR patients, which appear to affect in-hospital and midterm outcomes. Because of these discrepancies, early discrimination between these 2 etiologies of FMR might facilitate more tailored approaches to management.

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

J Thorac Cardiovasc Surg: 30 Dec 2020; epub ahead of print
Hirji SA, Cote CL, Javadikasgari H, Malarczyk A, McGurk S, Kaneko T
J Thorac Cardiovasc Surg: 30 Dec 2020; epub ahead of print | PMID: 33526277
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Impact:
Abstract

Quantifying invasiveness of clinical stage IA lung adenocarcinoma with computed tomography texture features.

Qiu ZB, Zhang C, Chu XP, Cai FY, ... Wu YL, Zhong WZ
Objectives
The study objectives were to establish and validate a nomogram for pathological invasiveness prediction in clinical stage IA lung adenocarcinoma and to help identify those potentially unsuitable for sublobar resection-based computed tomography texture features.
Method
Patients with clinical stage IA lung adenocarcinoma who underwent surgery at Guangdong Provincial People\'s Hospital between January 2015 and October 2018 were retrospectively reviewed. All surgically resected nodules were pathologically classified into less-invasive and invasive cohorts. Each nodule was manually segmented, and its computerized texture features were extracted. Clinicopathological and computed tomographic texture features were compared between 2 cohorts. A nomogram for distinguishing the pathological invasiveness was established and validated.
Results
Among 428 enrolled patients, 249 were diagnosed with invasive pathological subtypes. Smoking status (odds ratio, 2.906; 95% confidence interval, 1.285-6.579; P = .011), mean computed tomography attenuation value (odds ratio, 1.005, 95% confidence interval, 1.002-1.007; P < .001), and entropy (odds ratio, 8.536, 95% confidence interval, 3.478-20.951; P < .001) were identified as independent predictors for pathological invasiveness by multivariate logistics regression analysis. The nomogram showed good calibration (P = .182) with an area under the curve of 0.849 when validated with testing set data. Decision curve analysis indicated the potentially clinical usefulness of the model with respect to treat-all or treat-none scenario. Compared with intraoperative frozen-section, the nomogram performed better in pathological invasiveness diagnosis (area under the curve, 0.815 vs 0.670; P = .00095).
Conclusions
We established and validated a nomogram to compute the probability of invasiveness of clinical stage IA lung adenocarcinoma with great calibration, which may contribute to decisions related to resection extent.

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

J Thorac Cardiovasc Surg: 29 Dec 2020; epub ahead of print
Qiu ZB, Zhang C, Chu XP, Cai FY, ... Wu YL, Zhong WZ
J Thorac Cardiovasc Surg: 29 Dec 2020; epub ahead of print | PMID: 33541730
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Impact:
Abstract

Clinical impact of a small component of ground-glass opacity in solid-dominant clinical stage IA non-small cell lung cancer.

Watanabe Y, Hattori A, Nojiri S, Matsunaga T, ... Oh S, Suzuki K
Objective
Non-small cell lung cancers with a ground-glass opacity component have better prognosis than those with solid nodules of equivalent consolidation size. However, the impact of small ground-glass opacity components on prognosis is unknown. Therefore, we aimed to evaluate the significance of a small ground-glass opacity component in solid-dominant clinical stage IA non-small cell lung cancers.
Methods
We reviewed the cases of 543 surgically resected solid-dominant c-stage IA non-small cell lung cancers, which was defined as a tumor with consolidation tumor ratio of 0.75 or more on computed tomography. The patients were classified into 2 groups: 0.75 or less consolidation tumor ratio less than 1 (n = 126) and consolidation tumor ratio of 1 (n = 417). The prognoses were compared between the 2 groups.
Results
Among the 543 cases, multivariable analyses revealed that pure-solid appearance was a predictor of worse overall survival (hazard ratio, 2.051; 95% confidence interval, 1.044-4.028). Compared with the part-solid group, the pure-solid group was associated with poor survival in c-stages IA2 (5-year overall survival: 91.5% vs 76.8%, hazard ratio, 2.942; 95% confidence interval, 1.402-6.173; recurrence-free survival: 89.0% vs 68.8%, hazard ratio, 3.439; 95% confidence interval, 1.776-6.669) and IA3 (5-year overall survival: 93.5% vs 63.0%, hazard ratio, 5.110; 95% confidence interval, 1.607-16.241; recurrence-free survival: 80.5% vs 54.1%, hazard ratio, 2.789; 95% confidence interval, 1.290-6.027). The T categories significantly affected 5-year overall survival only in the pure-solid group (cT1a, 89.3%; cT1b, 76.8%; cT1c, 63.0%).
Conclusions
A small ground-glass opacity component has an impact on the prognosis of patients with solid-dominant c-stage IA non-small cell lung cancer. Therefore, c-stage IA non-small cell lung cancers should be evaluated separately for tumors with ground-glass opacity and pure-solid tumors.

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

J Thorac Cardiovasc Surg: 28 Dec 2020; epub ahead of print
Watanabe Y, Hattori A, Nojiri S, Matsunaga T, ... Oh S, Suzuki K
J Thorac Cardiovasc Surg: 28 Dec 2020; epub ahead of print | PMID: 33516459
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Impact:
Abstract

Tidal volume during 1-lung ventilation: A systematic review and meta-analysis.

Peel JK, Funk DJ, Slinger P, Srinathan S, Kidane B
Background
The selection of tidal volumes for 1-lung ventilation remains unclear, because there exists a trade-off between oxygenation and risk of lung injury. We conducted a systematic review and meta-analysis to determine how oxygenation, compliance, and clinical outcomes are affected by tidal volume during 1-lung ventilation.
Methods
A systematic search of MEDLINE and EMBASE was performed. A systematic review and random-effects meta-analysis was conducted. Pooled mean difference estimated arterial oxygen tension, compliance, and length of stay; pooled odds ratio was calculated for composite postoperative pulmonary complications. Risk of bias was determined using the Cochrane risk of bias and Newcastle-Ottawa tools.
Results
Eighteen studies were identified, comprising 3693 total patients. Low tidal volumes (5.6 [±0.9] mL/kg) were not associated with significant differences in partial pressure of oxygen (-15.64 [-88.53-57.26] mm Hg; P = .67), arterial oxygen tension to fractional intake of oxygen ratio (14.71 [-7.83-37.24]; P = .20), or compliance (2.03 [-5.22-9.27] mL/cmH2O; P = .58) versus conventional tidal volume ventilation (8.1 [±3.1] mL/kg). Low versus conventional tidal volume ventilation had no significant impact on hospital length of stay (-0.42 [-1.60-0.77] days; P = .49). Low tidal volumes are associated with significantly decreased odds of pulmonary complications (pooled odds ratio, 0.40 [0.29-0.57]; P < .0001).
Conclusions
Low tidal volumes during 1-lung ventilation do not worsen oxygenation or compliance. A low tidal volume ventilation strategy during 1-lung ventilation was associated with a significant reduction in postoperative pulmonary complications.

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

J Thorac Cardiovasc Surg: 24 Dec 2020; epub ahead of print
Peel JK, Funk DJ, Slinger P, Srinathan S, Kidane B
J Thorac Cardiovasc Surg: 24 Dec 2020; epub ahead of print | PMID: 33518385
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Impact:
Abstract

Sex differences in patients with cardiogenic shock requiring extracorporeal membrane oxygenation.

Wang AS, Nemeth S, Kurlansky P, Brodie D, ... Nir U, Takeda K
Objective
Our study assesses differences between male and female patients placed on venoarterial extracorporeal membrane oxygenation for cardiogenic shock.
Method
We retrospectively analyzed 574 adult patients placed on venoarterial extracorporeal membrane oxygenation for cardiogenic shock at our institution between January 2007 and December 2018. Baseline characteristics and outcomes were assessed. Propensity score matching was used to compare outcomes. The primary end point was in-hospital mortality. Secondary outcomes include limb ischemia, limb ischemia interventions, distal perfusion cannula placement, stroke, bleeding, and continuous venovenous hemofiltration initiation.
Results
There were 394 male patients (69%) and 180 female patients (31%). After adjusting for baseline differences, propensity score matching compared 171 male patients with 171 female patients. No difference was seen between men and women in in-hospital mortality (60.2% vs 56.7%; P = .59), limb ischemia (47.4% vs 45.6%; P = .83), limb ischemia surgery (15.2% vs 12.9%; P = .64), bleeding (49.7% vs 49.1%; P = 1), continuous venovenous hemofiltration initiation (39.2% vs 32.7%; P = .26), and stroke (8.2% vs 9.4%; P = .85). Multivariable logistic regression showed that female patients who died were more likely to have had chronic kidney disease (odds ratio [OR], 2.67; 95% confidence interval [CI], 1.09-6.53; P = .032) than surviving women. Male patients who died were more likely to have had coronary artery disease (OR, 2.25; 95% CI, 1.34-3.78; P = .002) and higher lactate levels (OR, 1.14; 95% CI, 1.08-1.21; P < .001) than surviving men. Women with cardiac transplant primary graft dysfunction were more likely to survive (OR, 0.04; 95% CI, 0.01-0.27; P = .001), whereas men with cardiac transplant primary graft dysfunction were less likely to survive (OR, 0.28; 95% CI, 0.11-0.71; P = .007), than patients with other shock etiologies.
Conclusions
After adjusting for baseline difference, there was no difference in outcomes between male and female patients despite differing risk profiles for in-hospital mortality. (supplementary video).

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

J Thorac Cardiovasc Surg: 22 Dec 2020; epub ahead of print
Wang AS, Nemeth S, Kurlansky P, Brodie D, ... Nir U, Takeda K
J Thorac Cardiovasc Surg: 22 Dec 2020; epub ahead of print | PMID: 33487423
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Impact:
Abstract

Less-invasive ventricular assist device implantation: A multicenter study.

Jawad K, Sipahi F, Koziarz A, Huhn S, ... Lichtenberg A, Saeed D
Background
Left ventricular assist device has been shown to be a safe and effective treatment option for patients with end-stage heart failure. However, there is limited evidence showing the effect of the implantation approach on postoperative morbidities and mortality. We aimed to compare left ventricular assist device implantation using conventional sternotomy versus less-invasive surgery including hemi-sternotomy and the minithoracotomy approach.
Methods
Between January 2014 and December 2018, 342 consecutive patients underwent left ventricular assist device implantation at 2 high-volume centers. Patient characteristics were prospectively collected. The propensity score method was used to create 2 groups in a 1:1 fashion. A competing risk regression model was used to evaluate time to death adjusting for competing risk of heart transplantation.
Results
The unmatched cohort included 241 patients who underwent left ventricular assist device implantation with the conventional sternotomy technique and 101 patients who underwent left ventricular assist device implantation with the less-invasive surgery technique. Propensity matching produced 2 groups each including 73 patients. In the matched groups, reexploration rate for bleeding was necessary in 17.9% (12/67) in the conventional sternotomy group compared with 4.1% (3/73) the less-invasive surgery group (P = .018). Intensive care unit stay for the less-invasive surgery group was significantly lower than for the sternotomy group (10.5 [interquartile range, 2-25.75] days vs 4 [interquartile range, 2-9.25] days, P = .008), as was hospital length of stay (37 [interquartile range, 27-61] days vs 25.5 [interquartile range, 21-42] days, P = .007). Mortality cumulative incidence for conventional surgery was 24% (95% confidence interval, 14.3-34.8) at 1 year and 26% (95% confidence interval, 15.9-37.4) at 2 years for patients without heart transplantation. Mortality cumulative incidence for less-invasive surgery was 22.5% (95% confidence interval, 12.8-33.8) at 1 year and 25.2% (95% confidence interval, 14.5-37.4) at 2 years for patients without heart transplantation. There was no difference in cumulative mortality incidence when adjusting for competing risk of heart transplantation (subdistribution hazard, 0.904, 95% confidence interval, 0.45-1.80, P = .77).
Conclusions
The less-invasive surgery approach is a safe technique for left ventricular assist device implantation. Less-invasive surgery was associated with a significant reduction in the postoperative bleeding complications and duration of hospital stay, with no significant difference in mortality incidence.

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

J Thorac Cardiovasc Surg: 22 Dec 2020; epub ahead of print
Jawad K, Sipahi F, Koziarz A, Huhn S, ... Lichtenberg A, Saeed D
J Thorac Cardiovasc Surg: 22 Dec 2020; epub ahead of print | PMID: 33487414
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Impact:
Abstract

Correlating oxygen delivery on cardiopulmonary bypass with Society of Thoracic Surgeons outcomes following cardiac surgery.

Magruder JT, Weiss SJ, DeAngelis KG, Haddle J, ... Acker MA, Penn Perfusion Team Working Group
Background
The relationship between low oxygen delivery (DO2) on cardiopulmonary bypass and morbidity and mortality following cardiac surgery remains unexamined.
Methods
We reviewed patients undergoing Society of Thoracic Surgeons index procedures from March 2019 to July 2020, coincident with implementation of a new electronic perfusion record that provides for continuous recording of DO2 and flow parameters. Continuous perfusion variables were analyzed using area-over-the-curve (AOC) calculations below predefined thresholds (DO2 <280 mL O2/min/m2, cardiac index <2.2 L/min, hemoglobin < baseline, and mean arterial pressure <65 mm Hg) to quantify depth and duration of potentially harmful exposures. Multivariable logistic regression adjusted by Society of Thoracic Surgeons predicted-risk scores were used to assess for relationship of perfusion variables with the primary composite outcome of any Society of Thoracic Surgeons index procedure, as well as individual Society of Thoracic Surgeons secondary outcomes (eg, mortality, renal failure, prolonged ventilation >24 hours, stroke, sternal wound infection, and reoperation).
Results
Eight hundred thirty-four patients were included; 42.7% (356) underwent isolated coronary artery bypass grafting (CABG), whereas 57.3% underwent nonisolated CABG (eg, valvular or combined CABG/valvular operations). DO2 <280-AOC trended toward association with the primary outcome across all cases (P = .07), and was significantly associated for all nonisolated CABG cases (P = .02)-more strongly than for cardiac index <2.2-AOC (P = .04), hemoglobin <7-AOC (P = .51), or mean arterial pressure <65-AOC (P = .11). Considering all procedures, DO2 <280-AOC was independently associated prolonged ventilation >24 hours (P = .04), an effect again most pronounced in nonisolated-CABG cases (P = .002), as well as acute kidney injury <72 hours (P = .04). Patients with glomerular filtration rate <65 mL/min and baseline hemoglobin <12.5 g/dL appeared especially vulnerable.
Conclusions
Low DO2 on bypass may be associated with morbidity/mortality following cardiac surgery, particularly in patients undergoing nonisolated CABG. These results underscore the importance of goal-directed perfusion strategies.

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

J Thorac Cardiovasc Surg: 18 Dec 2020; epub ahead of print
Magruder JT, Weiss SJ, DeAngelis KG, Haddle J, ... Acker MA, Penn Perfusion Team Working Group
J Thorac Cardiovasc Surg: 18 Dec 2020; epub ahead of print | PMID: 33485654
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Abstract

A conservative screening algorithm to determine candidacy for robotic mitral valve surgery.

Chemtob RA, Wierup P, Mick SL, Javorski MJ, ... Gillinov AM, Cardiac Robotic Surgery Working Group at Cleveland Clinic
Objective
Patient selection for robotically assisted mitral valve repair remains controversial. We assessed outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for robotic surgery.
Methods
From January 2014 to January 2019, a screening algorithm that included transthoracic echocardiography and computed tomography scanning was rigorously applied by 3 surgeons to assess candidacy of 1000 consecutive patients with isolated degenerative mitral valve disease (age 58 ± 11 years, 67% male) for robotic surgery. Screening results and hospital outcomes of those selected for robotic versus sternotomy approaches were compared.
Results
With application of the screening algorithm, 605 patients were selected for robotic surgery. Common reasons for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74/292, 25%), femoral artery diameter <7 mm (n = 60/292, 20%), mitral annular calcification (n = 83/390, 21%), aortic regurgitation (n = 100/391, 26%), and reduced left ventricular function (n = 126/391, 32%). Mitral valve repair was accomplished in 996. Compared with sternotomy, patients undergoing robotic surgery had less new-onset atrial fibrillation (n = 144/582, 25% vs n = 125/373, 34%; P = .002), fewer red blood cell transfusions (n = 61/601, 10% vs 69/395, 17%; P < .001), and shorter hospital stay (5.2 ± 2.9 days vs 5.9 ± 2.1 days; P < .001). No hospital deaths occurred, and occurrence of postoperative stroke in the robotic (n = 3/605, 0.50%) and sternotomy (n = 4/395, 1.0%; P = .3) groups was similar.
Conclusions
This conservative screening algorithm qualified 60% of patients with isolated degenerative mitral valve disease for robotic surgery. Outcomes were comparable with those obtained with sternotomy, validating this as an approach to select patients for robotic mitral valve surgery.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 16 Dec 2020; epub ahead of print
Chemtob RA, Wierup P, Mick SL, Javorski MJ, ... Gillinov AM, Cardiac Robotic Surgery Working Group at Cleveland Clinic
J Thorac Cardiovasc Surg: 16 Dec 2020; epub ahead of print | PMID: 33436297
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Abstract

Equal means equal: Cardiothoracic surgery in its second century.

Moon MR
Objective
As the specialty of cardiothoracic surgery turns the corner into its second century of existence, there has been an uptick in the number of women and underrepresented minorities entering the field, but we have a long way to go before race and gender equity prevails.
Methods
In this report, specific barriers to diversity without exclusion and mechanisms to breakdown these barriers will be explored.
Results
Barriers to inclusion include a long-standing deficiency in exposure, encouragement, mentorship, and sponsorship to actively attract underrepresented groups to the specialty. Diversity will not occur passively. It will take a concerted effort best employed through a top-down approach at the local and national level, and it has to seem normal.
Conclusions
Cardiothoracic surgery is an outstanding field for anyone and everyone who seeks a challenging, rewarding career, regardless of their gender, race, or ethnic background. It is the responsibility of leadership to dispel the tradition that certain individuals are not welcome.

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

J Thorac Cardiovasc Surg: 16 Dec 2020; epub ahead of print
Moon MR
J Thorac Cardiovasc Surg: 16 Dec 2020; epub ahead of print | PMID: 33487415
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Abstract

Comparison of del Nido and histidine-tryptophan-ketoglutarate cardioplegic solutions in minimally invasive cardiac surgery.

Lee CH, Kwon Y, Park SJ, Lee JW, Kim JB
Objective
We examined the safety and efficacy of del Nido cardioplegic solution compared with histidine-tryptophan-ketoglutarate cardioplegic solution in minimally invasive cardiac surgery.
Methods
Patients who underwent minimally invasive cardiac surgery using del Nido or histidine-tryptophan-ketoglutarate from 2015 to 2019 were enrolled. Various clinical outcomes were compared between the groups. Postoperative laboratory findings including the levels of electrolytes, cardiac enzymes (creatine kinase-MB and troponin I), and serial blood lactate were also measured and compared. Based on 28 baseline covariates, propensity score matching was performed to reduce selection bias.
Results
Among 766 patients, del Nido and histidine-tryptophan-ketoglutarate were used in 330 patients (43.1%) and 436 patients (56.9%), respectively. There were no significant intergroup differences in postoperative clinical outcomes and early adverse outcomes among 228 pairs of propensity score-matched patients. Immediate postoperative sodium levels were within the normal range in both groups without a significant difference (P = .50). However, peak creatine kinase-MB (median, 31.9 vs 37.7 ng/mL, P = .026) and troponin I (6.9 vs 9.1 ng/mL, P = .014) levels were significantly lower in the del Nido group. Linear regression analysis revealed a significant association between the peak cardiac enzyme levels and the cardiac ischemic time depending on the cardioplegia type, with lower cardiac isoenzymes for del Nido over histidine-tryptophan-ketoglutarate (P < .001) until the crossover point at the cardiac ischemic time over 100 minutes.
Conclusions
In comparison with histidine-tryptophan-ketoglutarate solution, del Nido solution seems to have acceptable safety and efficacy with good myocardial protection in minimally invasive cardiac surgery. Further studies focusing on complex surgeries requiring longer cardiac ischemic time are needed.

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

J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print
Lee CH, Kwon Y, Park SJ, Lee JW, Kim JB
J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print | PMID: 33487412
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Abstract

Intrapleural interleukin-2-expressing oncolytic virotherapy enhances acute antitumor effects and T-cell receptor diversity in malignant pleural disease.

Ekeke CN, Russell KL, Murthy P, Guo ZS, ... Lotze MT, Dhupar R
Objective
The mainstay of treatment for patients with malignant pleural disease is fluid drainage and systemic therapy. A tumor-specific oncolytic virus or T-cell-activating interleukin-2 immunotherapy may provide an opportunity for local control. We previously developed a vaccinia virus-expressing interleukin-2, an oncolytic virus that mediated tumor regression in preclinical peritoneal tumor models with expansion of tumor-infiltrating lymphocytes. We evaluated the antitumor efficacy and immune modulatory effects of vaccinia virus-expressing interleukin-2 in malignant pleural disease.
Methods
A murine model of malignant pleural disease was established with percutaneous intrapleural deposition of the Lewis lung carcinoma cell line and monitored with bioluminescent imaging. After intrapleural or systemic administration of vaccinia viruses (vaccinia virus yellow fluorescent protein control, vaccinia virus-expressing interleukin-2), systemic anti-programmed cell death-1 antibody, or combination therapy (vaccinia virus-expressing interleukin-2 and anti-programmed cell death-1), tumor mass, immune cell infiltration, T-cell receptor diversity, and survival were assessed.
Results
Intrapleural vaccinia virus resulted in significant tumor regression compared with phosphate-buffered saline control (P < .05). Inclusion of the interleukin-2 transgene further increased intratumoral CD8+ T cells (P < .01) and programmed cell death-1 expression on CD8+ tumor-infiltrating lymphocytes (P < .001). Intrapleural vaccinia virus-expressing interleukin-2 was superior to systemic vaccinia virus-expressing interleukin-2, with reduced tumor burden (P < .0001) and improved survival (P < .05). Intrapleural vaccinia virus-expressing interleukin-2 alone or combined treatment with systemic anti-programmed cell death-1 reduced tumor burden (P < .01), improved survival (P < .01), and increased intratumoral αβ T-cell receptor diversity (P < .05) compared with systemic anti-programmed cell death-1 monotherapy.
Conclusions
Intrapleural vaccinia virus-expressing interleukin-2 reduced tumor burden and enhanced survival in a murine malignant pleural disease model. Increased CD8+ tumor-infiltrating lymphocytes and αβ T-cell receptor diversity are associated with enhanced response. Clinical trials will enable assessment of intrapleural vaccinia virus-expressing interleukin-2 therapy in patients with malignant pleural disease.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print
Ekeke CN, Russell KL, Murthy P, Guo ZS, ... Lotze MT, Dhupar R
J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print | PMID: 33485667
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Abstract

Twenty-four-hour normothermic perfusion of isolated ex vivo hearts using plasma exchange.

Tchouta L, Drake D, Hoenerhoff M, Rojas-Pena A, ... Bartlett R, University of Michigan Department of Surgery Extracorporeal Life Support Laboratory
Objective
Cross-circulation of plasma from a paracorporeal animal allows successful ex vivo heart perfusion (EVHP) for 3 days. Little is known about the feasibility of prolonged EVHP without a paracorporeal animal. These experiments evaluated plasma exchange (PX) that infuses fresh plasma, whereas an equal amount is removed to replace paracorporeal cross-circulation.
Methods
Ten hearts were procured from 8 to 10 kg piglets and maintained with EVHP. The EVHP circuit was primed with platelet- and leukocyte-reduced blood. Plasma obtained from stored porcine blood (4°C for ≤7 days) was infused and removed with a plasma separator at 1 mL/h/g cardiac tissue (n = 5) in the PX group. Controls (n = 5) used the same EVHP without PX. Antegrade aortic perfusion was adjusted to reach physiologic coronary flow of 0.7 to 1.2 mL/min/g, normothermia (37°C), and hemoglobin ≥8 g/dL. Viability was assessed by hemodynamic metrics, metabolic assays, and histopathology.
Results
All PX hearts remained viable for 24 hours compared with only 1 control (P = .015). Coronary resistance was higher in the PX versus controls (1.06 ± 0.06 mm Hg/mL/min; 0.58 ± 0.02 mm Hg/mL/min [P < .05]). Lactate levels were lower in PX (2.8-4.2 mmol/L) versus controls (3.6-7.6 mmol/L) (P < .05). PX demonstrated a trend toward preservation of left ventricle systolic pressure (63.0 ± 10.9 mm Hg) versus controls (37 ± 22.0 mm Hg) (P > .05). In mixed effect models, oxygen consumption was higher with PX (P < .05). Histopathologic evaluation confirmed extensive myocardial degeneration and worse interstitial edema in controls.
Conclusions
These results demonstrate that EVHP can be successfully maintained for at least 24 hours using continuous PX. This eliminates the need for a paracorporeal animal and provides an important step toward clinical application.

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

J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print
Tchouta L, Drake D, Hoenerhoff M, Rojas-Pena A, ... Bartlett R, University of Michigan Department of Surgery Extracorporeal Life Support Laboratory
J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print | PMID: 33485659
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Abstract

Aortic valve repair in children without use of a patch.

Wallace FRO, Buratto E, Naimo PS, Brink J, ... Brizard CP, Konstantinov IE
Background
We aimed to assess the long-term outcomes of children in whom the aortic valve could be repaired without the use of patch material. We hypothesized that if the aortic valve is of sufficiently good quality to perform repair without patches, a durable repair could be achieved.
Methods
All children (n = 102) who underwent aortic valve repair without the use of a patch between 1980 and 2016 were reviewed.
Results
The median patient age at operation was 2 years (interquartile range, 1 month to 9.6 years). There were 25 neonates and 17 infants. There was no operative mortality. Mean overall survival at 10 years was 97.7% ± 0.01% (95% confidence interval, [CI] 91.0%-99.4%). Forty-three patients (42.2%) required 56 aortic valve reoperations, including 24 redo aortic valve repairs, 22 Ross procedures, 8 mechanical aortic valve replacements, and 2 homograft aortic valve replacements. Mean freedom from aortic valve reoperation at 10 years was 57.4% ± 0.06% (95% CI, 44.9%-68.1%), and freedom from aortic valve replacement at 10 years was 74.5% ± 0.05% (95% CI, 63.0%-82.9%) at 10 years. Freedom from aortic valve reoperation at 10 years was 33.1% ± 0.1% (95% CI, 14.5%-53.2%) in neonates and 68.9% ± 0.06% (95% CI, 54.5%-79.6%) in older children (P < .01).
Conclusions
In approximately one-third of children undergoing aortic valve repair, the repair could be achieved without patches. In these children, aortic valve repair was achieved without operative mortality. Infants and older children have low reoperation rates, whereas reoperation rates in neonates are higher. Initial repair allows valve replacement to be delayed to later in childhood, when a more durable result may be achieved.

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

J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print
Wallace FRO, Buratto E, Naimo PS, Brink J, ... Brizard CP, Konstantinov IE
J Thorac Cardiovasc Surg: 12 Dec 2020; epub ahead of print | PMID: 33516462
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Abstract

Does supply meet demand? A comparison of perfusion strategies on cerebral metabolism in a neonatal swine model.

Mavroudis CD, Ko T, Volk LE, Smood B, ... Mascio CE, Kilbaugh TJ
Objective
We aimed to determine the effects of selective antegrade cerebral perfusion compared with other perfusion strategies on indices of cerebral blood flow, oxygenation, cellular stress, and mitochondrial function.
Methods
One-week-old piglets (n = 41) were assigned to 5 treatment groups. Thirty-eight were placed on cardiopulmonary bypass. Of these, 30 were cooled to 18°C and underwent deep hypothermic circulatory arrest (n = 10), underwent selective antegrade cerebral perfusion at 10 mL/kg/min (n = 10), or remained on continuous cardiopulmonary bypass (deep hypothermic cardiopulmonary bypass, n = 10) for 40 minutes. Other subjects remained on normothermic cardiopulmonary bypass (n = 8) or underwent sham surgery (n = 3). Novel, noninvasive optical measurements recorded cerebral blood flow, cerebral tissue oxyhemoglobin concentration, oxygen extraction fraction, total hemoglobin concentration, and cerebral metabolic rate of oxygen. Invasive measurements of cerebral microdialysis and cerebral blood flow were recorded. Cerebral mitochondrial respiration and reactive oxygen species generation were assessed after the piglets were killed.
Results
During hypothermia, deep hypothermic circulatory arrest piglets experienced increases in oxygen extraction fraction (P < .001), indicating inadequate matching of oxygen supply and demand. Deep hypothermic cardiopulmonary bypass had higher cerebral blood flow (P = .046), oxyhemoglobin concentration (P = .019), and total hemoglobin concentration (P = .070) than selective antegrade cerebral perfusion, indicating greater oxygen delivery. Deep hypothermic circulatory arrest demonstrated worse mitochondrial function (P < .05), increased reactive oxygen species generation (P < .01), and increased markers of cellular stress (P < .01). Reactive oxygen species generation was increased in deep hypothermic cardiopulmonary bypass compared with selective antegrade cerebral perfusion (P < .05), but without significant microdialysis evidence of cerebral cellular stress.
Conclusions
Selective antegrade cerebral perfusion meets cerebral metabolic demand and mitigates cerebral mitochondrial reactive oxygen species generation. Excess oxygen delivery during deep hypothermia may have deleterious effects on cerebral mitochondria that may contribute to adverse neurologic outcomes. We describe noninvasive measurements that may help guide perfusion strategies.

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

J Thorac Cardiovasc Surg: 10 Dec 2020; epub ahead of print
Mavroudis CD, Ko T, Volk LE, Smood B, ... Mascio CE, Kilbaugh TJ
J Thorac Cardiovasc Surg: 10 Dec 2020; epub ahead of print | PMID: 33485668
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Abstract

Functional outcome after single-stage laryngotracheal reconstruction with rib cartilage grafting.

Schweiger T, Roesner I, de Faria Soares Rodrigues I, Evermann M, ... Klepetko W, Hoetzenecker K
Objective
Single-stage laryngotracheal reconstruction (SSLTR) provides a definite surgical treatment for patients with complex glotto-subglottic stenosis. To date, the influence of SSLTR on the functional outcome after surgery has not been analyzed.
Methods
A retrospective analysis of all patients receiving a SSLTR between November 2012 and October 2019 was performed. Preoperatively and 3 months postoperatively, patients received a full functional evaluation, including spirometry; voice measurements (eg, fundamental frequency; dynamic range, singing voice range, and perceptual voice evaluation using the Roughness-Breathiness-Hoarseness [RBH] score, and fiberoptic endoscopic evaluation of swallowing [FEES]).
Results
A total of 15 patients with a mean age of 45 ± 17 years underwent SSTLR. Two (13%) patients were men and 13 (87%) were women. The majority of patients (67%) had undergone previous surgical or endoscopic treatment attempts that had failed. At the 3-month follow-up visit, none of the patients had signs of penetration or aspiration in their swallowing examination. Voice measurements revealed a significantly lower fundamental voice frequency (201.0 Hz vs 155.5 Hz; P = .006), whereas voice range (19.1 semitones vs 14.9 semitones; P = .200) and dynamic range (52.5 dB vs 53.0 dB; P = .777) was hardly affected. The median RBH score changed from R1 B0 H1 to R2 B1 H2. In spirometry, breathing capacity increased significantly (peak expiratory flow, 44% vs 87% [P < .001] and mean expiratory flow at 75% of vital capacity, 48% vs 90% [P < .001]). During a median follow-up of 32.5 months (range, 7-88 months), none of the patients developed re-stenosis.
Conclusions
For complex glotto-subglottic stenoses, durable long-term airway patency together with reasonable voice quality and normal deglutition can be achieved by SSLTR.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 10 Dec 2020; epub ahead of print
Schweiger T, Roesner I, de Faria Soares Rodrigues I, Evermann M, ... Klepetko W, Hoetzenecker K
J Thorac Cardiovasc Surg: 10 Dec 2020; epub ahead of print | PMID: 33640122
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Abstract

Latent outflow tract obstruction in hypertrophic cardiomyopathy: Clinical characteristics and outcomes of septal myectomy.

Cui H, Schaff HV, Nishimura RA, Dearani JA, Geske JB, Ommen SR
Objective
This investigation analyzed clinical characteristics of patients with hypertrophic cardiomyopathy (HCM) and latent left ventricular outflow tract (LVOT) and outcomes following septal myectomy.
Methods
We reviewed patients with HCM and LVOT obstruction undergoing septal myectomy from 2001 to 2016 at our center. Follow-up data on functional status were obtained through mailed survey questionnaires.
Results
There were 629 (31.8%) patients with latent obstruction (resting LVOT gradient <30 mm Hg, provoked gradient >30 mm Hg) among 1981 patients undergoing septal myectomy. Patients with latent obstruction were more likely to be male (65.7% vs 51.8%, P < .001), but there were no important differences in other clinical characteristics. The New York Heart Association functional classes and measured/predicted maximal oxygen consumption (62 [51, 72] vs 60 [48, 72], P = .158) in cardiopulmonary exercise tests were comparable between the 2 groups. Patients with latent obstruction had both lower septal thickness and lower posterior wall thickness. Median intraoperative provoked pressure gradient decreased from 96 (68, 126) mm Hg to 0 (0, 6) mm Hg after myectomy (P < .001). There was no difference in early (<30 days) deaths (3/629 vs 5/1352, P = .726) and long-term survival between patients with latent obstruction and resting obstruction. In follow-up, both general health status and New York Heart Association functional class were significantly improved following septal myectomy.
Conclusions
Patients with HCM and latent LVOT obstruction generally have milder left ventricular hypertrophy but similarly impaired functional capacity compared to those with resting obstruction. Septal myectomy improves functional capacity and symptoms.

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

J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print
Cui H, Schaff HV, Nishimura RA, Dearani JA, Geske JB, Ommen SR
J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print | PMID: 33468328
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Abstract

Safety of continuous 12-hour delivery of antimicrobial doses of inhaled nitric oxide during ex vivo lung perfusion.

Michaelsen VS, Ribeiro RVP, Ali A, Wang A, ... Keshavjee S, Cypel M
Introduction
High-dose nitric oxide (NO) has been shown effective against a variety of micro-organisms in vitro, including common bacteria found in donor organs. However, clinical obstacles related to its implementation in vivo are the formation of methemoglobin and the accumulation of toxic nitrogen compounds. Ex vivo lung perfusion (EVLP) is a platform that allows for organ maintenance with an acellular perfusion solution, thus overcoming these limitations. The present study explores the safety of continuous high-dose inhaled (iNO) during EVLP for an extended period of 12 hours.
Methods
Lungs procured from Yorkshire pigs were randomized into control (standard ventilation) and treatment (standard ventilation + 200 ppm iNO) groups, then perfused with an acellular solution for 12 hours (n = 4/group). Lung physiology and biological markers were evaluated.
Results
After 12 hours of either standard EVLP or EVLP + 200 ppm iNO, we did not notice any significant physiologic difference between the groups: pulmonary oxygenation (P = .586), peak airway pressures (P = .998), and dynamic (P = .997) and static (P = .908) lung compliances. In addition, no significant differences were seen among proinflammatory cytokines measured in perfusate and lung tissue. Importantly, most common toxic compounds were kept at safe levels throughout the treatment course.
Conclusions
High-dose inhaled NO delivered continuously over 12 hours appears to be safe without inducing any significant pulmonary inflammation or deterioration in lung function. These findings support further efficacy studies to explore the use of iNO for the treatment of infections in donor lungs during EVLP.

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

J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print
Michaelsen VS, Ribeiro RVP, Ali A, Wang A, ... Keshavjee S, Cypel M
J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print | PMID: 33478833
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Abstract

Minimally invasive repair of pectus excavatum by the Nuss procedure: The learning curve.

de Loos ER, Daemen JHT, Pennings AJ, Heuts S, ... Hulsewé KWE, Vissers YLJ
Objectives
To define the learning process of minimally invasive repair of pectus excavatum by the Nuss procedure through assessment of consecutive procedural metrics.
Methods
A single-center retrospective observational cohort study was conducted of all consecutive Nuss procedures performed by individual surgeons without previous experience between June 2006 and December 2018. Surgeons were proctored during their initial 10 procedures. The learning process after the proctoring period was evaluated using nonrisk-adjusted cumulative sum (ie, observed minus expected) failure charts of complications. An acceptable and unacceptable complication rate of 10% and 20% were used. Logarithmic trend lines were used to assess over-time performance regarding operation time.
Results
Two-hundred twenty-two consecutive Nuss procedures by 3 general thoracic surgeons were evaluated. Cumulative sum charts showed an average performance from the first procedure after being proctored onward for all surgeons, whereas surgeon B demonstrated a statistically significant complication rate equal to or less than 10% after 59 cases. Post-hoc sensitivity analyses using a stricter acceptable and unacceptable complication rate of 6% and 12% also showed an average performance for all surgeons. Although, the median time between consecutive procedures ranged from 7 to 35 days, no frequency-outcome relationship was observed. In addition, surgeons required the same average operation time throughout their entire experience.
Conclusions
After a 10-procedure proctoring period, repair of pectus excavatum by the Nuss procedure is a safe procedure to adopt and perform without a typical (complication based) learning curve while performing at least 1 procedure per 35 days.

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

J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print
de Loos ER, Daemen JHT, Pennings AJ, Heuts S, ... Hulsewé KWE, Vissers YLJ
J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print | PMID: 33478832
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Impact:
Abstract

Superior restoration of left ventricular performance after prolonged single-dose del Nido cardioplegia in conjunction with terminal warm blood cardioplegic reperfusion.

Nakao M, Morita K, Shinohara G, Saito S, Kunihara T
Objectives
An incomplete restoration of left ventricular contractility after del Nido cardioplegia was noted in our recent study. This study tested the hypothesis that terminal warm blood cardioplegia promotes a prompt restoration of left ventricular performance after a prolonged single-dose del Nido cardioplegia.
Methods
Fourteen piglets were subjected to 120 minutes of arrest by del Nido cardioplegia without terminal warm blood cardioplegia (del Nido cardioplegia group; n = 7) or with terminal warm blood cardioplegia before reperfusion (terminal warm blood cardioplegia group; n = 7). The other 7 piglets underwent total cardiopulmonary bypass without ischemia/reperfusion for 150 minutes (control group). Left ventricular function was assessed by percent recovery of end-systolic elastance as the contractility and percent end-diastolic pressure-volume relationship as the compliance using a conductance catheter. Troponin T and the mitochondrial score were also measured.
Results
Depressed percent recovery of end-systolic elastance was sustained in the del Nido cardioplegia group, and a prompt restoration of end-systolic elastance was achieved using terminal warm blood cardioplegia (57.9 ± 17.8 vs 94.7 ± 13.1, P < .028). Percent end-diastolic pressure-volume relationship at the early phase was better in the terminal warm blood cardioplegia compared with the del Nido group (88.5 ± 24.0 vs 101.4 ± 16.8, P = .050). Troponin T was higher in the terminal warm blood cardioplegia compared with the control group (0.80% ± 0.21% and 1.49% ± 0.31%, respectively, P = .002). The mitochondrial score was equivalent in all groups. Spontaneous restoration to sinus rhythm was more frequent in the terminal warm blood cardioplegia group than in the del Nido cardioplegia group (6/7 vs 1/7, P < .028).
Conclusions
The supplementary use of terminal warm blood cardioplegia achieved prolongation of the safe ischemic time up to 120 minutes for a single-dose application.

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

J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print
Nakao M, Morita K, Shinohara G, Saito S, Kunihara T
J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print | PMID: 33485669
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Impact:
Abstract

The influence of tobacco load versus smoking status on outcomes following lobectomy for lung cancer in a statewide quality collaborative.

Al Natour RH, He C, Clark MJ, Welsh R, Chang AC, Adams KN
Background
Collaborative quality consortia can facilitate implementation of quality measures arising from clinical databases. Our statewide general thoracic surgery (GTS) collaborative investigated the influences of cigarette smoking status on mortality and major morbidity following lobectomy for lung cancer.
Methods
Society of Thoracic Surgeons General Thoracic Surgery Database records were identified from 14 institutions participating in a statewide thoracic surgical quality collaborative between 2012 and 2017. We excluded patients with nonelective procedures, stage 0 tumors, American Society of Anesthesiologists class VI disease, and missing clinical characteristics. Outcomes analysis included the combined mortality and major postoperative morbidity rates and the influence of patient characteristics, including smoking status, on composite rate and on postoperative complications.
Results
The study cohort included 2267 patient records for analysis. Overall combined mortality and major morbidity rate was 10.2% (n = 231). Postoperative 30-day mortality was 1.5%, and major morbidity 9.6%. Significant predictors of the combined outcome included male sex (P = .004), body mass index (P < .001), Zubrod score (P = .02), smoking pack-years (P = .03), and thoracotomy (P < .001). Higher American Society of Anesthesiologists disease class and advanced tumor stage were marginally associated with worse combined outcome (P = .06). Smoking status; that is, current, past (no smoking within 30 days), or never smoked, was not associated with worse combined outcome (P = .56) and had no significant influence on major complications.
Conclusions
Smoking status was not associated with worse outcomes; however, smoking dose (pack-years) was associated with worse combined mortality and major morbidity. A statewide quality collaborative provides constructive feedback for participating institutions and surgeons, promoting quality improvement in perioperative patient care strategies and improved outcomes.

Copyright © 2020. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print
Al Natour RH, He C, Clark MJ, Welsh R, Chang AC, Adams KN
J Thorac Cardiovasc Surg: 09 Dec 2020; epub ahead of print | PMID: 33558118
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Impact:
Abstract

Surgery for pre- and minimally invasive lung adenocarcinoma.

Zhang Y, Ma X, Shen X, Wang S, ... Hu H, Chen H
Objective
Adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) are the pre- and minimally invasive forms of lung adenocarcinoma. We aimed to investigate safety results and survival outcomes following different types of surgical resection in a large sample of patients with AIS/MIA.
Methods
Medical records of patients with lung AIS/MIA who underwent surgery between 2012 and 2017 were retrospectively reviewed. Clinical characteristics, surgical types and complications, recurrence-free survival, and overall survival were investigated.
Results
A total of 1644 patients (422 AIS and 1222 MIA) were included. The overall surgical complication rate was significantly lower in patients receiving wedge resection (1.0%), and was comparable between patients undergoing segmentectomy (3.3%) or lobectomy (5.6%). Grade ≥ 3 complications occurred in 0.1% of patients in the wedge resection group, and in a comparable proportion of patients in the segmentectomy group (1.5%) and the lobectomy group (1.5%). There was no lymph node metastasis. The 5-year recurrence-free survival rate was 100%. The 5-year overall survival rate in the entire cohort was 98.8%, and was comparable among the wedge resection group (98.8%), the segmentectomy group (98.2%), and the lobectomy group (99.4%).
Conclusions
Sublobar resection, especially wedge resection without lymph node dissection, may be the preferred surgical procedure for patients with AIS/MIA. If there are no risk factors, postoperative follow-up intervals may be extended. These implications should be validated in further studies.

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

J Thorac Cardiovasc Surg: 07 Dec 2020; epub ahead of print
Zhang Y, Ma X, Shen X, Wang S, ... Hu H, Chen H
J Thorac Cardiovasc Surg: 07 Dec 2020; epub ahead of print | PMID: 33485660
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Abstract

Undersizing mitral annuloplasty alters left ventricular mechanics in a swine model of ischemic mitral regurgitation.

Xu D, McBride E, Kalra K, Wong K, ... Sarin EL, Padala M
Objective
Undersizing mitral annuloplasty (UMA) is a frequently used surgical repair technique to correct ischemic mitral regurgitation in patients with heart failure. In this study, we sought to test the hypothesis that downsizing the mitral annulus can adversely affect the shape and mechanics of the left ventricle inhibiting its functional recovery.
Methods
Eighteen farm swine that underwent an inferolateral myocardial infarction and developed ischemic mitral regurgitation of >2+ severity after 2 months were assigned as follows: 9 swine received an undersized mitral annuloplasty, 6 received papillary muscle approximation (PMA), and 3 animals did not receive any other intervention. Animals lived another 3 months and cardiac magnetic resonance imaging was performed before termination to assess ventricle mechanics and function.
Results
Ejection fraction was comparable between the 2 repair groups before surgery, but was significantly lower in UMA at 38.89% ± 7.91% versus 50.83% ± 9.04% in the PMA group (P = .0397). Animals receiving UMA had lower regional peak fractional shortening and reduced systolic and diastolic radial velocities compared with PMA and in some regions were lower than sham. Animals that underwent UMA had higher circumferential strain than sham, but lower than PMA. UMA animals have lower longitudinal strain compared to sham group and lower LV torsion than PMA.
Conclusions
Undersizing the mitral annulus with an annuloplasty ring can restore valvular competence, but unphysiologically impair ventricle mechanics. Mitral valve repair strategies should focus not only on restoring valve competence, but preserving ventricle mechanics.

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

J Thorac Cardiovasc Surg: 05 Dec 2020; epub ahead of print
Xu D, McBride E, Kalra K, Wong K, ... Sarin EL, Padala M
J Thorac Cardiovasc Surg: 05 Dec 2020; epub ahead of print | PMID: 33288234
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This program is still in alpha version.