Thoracic Surgery Research Articles

Antegrade cerebral perfusion via the right subclavian artery during open distal arch or proximal descending aortic repair from left thoracotomy.

In the current endovascular era, open surgery through left posterolateral thoracotomy (PLT) with moderate to deep hypothermic circulatory arrest (DHCA) remains an alternative for treating chronic distal arch or proximal descending aortic diseases, allowing cardiovascular surgeons to definitively repair the aorta in a single stage. When utilizing this approach, this report illustrates an alternative surgical technique for antegrade body perfusion during cooling, antegrade selective cerebral perfusion (ASCP), and rewarming, through a prosthetic graft on the right subclavian artery (RSA). This report shows the safety and feasibility of this technique during open distal arch and/or proximal descending aortic surgery through left PLT, after shifting the patient from a supine to the right lateral decubitus position.

Advancements in the Management of Postoperative Air Leak following Thoracic Surgery: From Traditional Practices to Innovative Therapies.

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.

Lessons from short chest drain management for primary spontaneous pneumothorax.

Video-assisted thoracic surgery (VATS) bullectomy is the mainstay treatment for primary spontaneous pneumothorax (PSP) but we encounter patients with pain due to chest tube. This study investigated the postoperative outcomes of shortened silicone drain as a chest tube after VATS bullectomy to reduce pain. The current study included patients aged < 30years who underwent VATS bullectomy for PSP. Patients with normal intrathoracic lengths of the silicone drain placed in a loop at the apex toward the diaphragm were categorized as Group L, whereas those with the silicone drain shortened to approximately 10cm and placed toward the apex were classified as Group S. Postoperative pain evaluated using a numerical rating scale (NRS) and other perioperative outcomes were compared between the groups. Altogether, 43 patients were included, with 22 in Group L and 21 in Group S, respectively. The NRS before chest tube removal was significantly lower in Group S (mean, 2.1) than in Group L (4.4; p = 0.001). In Group L, 4 patients (p = 0.017) required early chest tube removal than expected due to severe pain whereas none in Group S required this intervention; additionally, more patients needed additional analgesics than in Group S (p = 0.003). In VATS bullectomy for PSP, the pain intensity could be reduced by shortening the intrathoracic length of the silicone drain, compared to a longer intrathoracic length of the silicon drain. Our findings contribute to the establishment of optimal postoperative management of general thoracic surgery.

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners.

Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.

Inter-prefectural and urban-rural regional disparities in lung cancer surgery: a Japanese nationwide population-based cohort study from 2017 to 2019.

To investigate regional disparities in lung cancer surgery in Japan. The annual incidence of lung cancer, lung cancer surgery, and the number of board-certified thoracic surgeons in Japan during 2014-2019 were investigated using a national open database. Lung cancer surgeries were categorized by procedure (wedge resection, segmentectomy, lobectomy, pneumonectomy) and approach (open, thoracoscopic). Disparities in 47 prefectures and urban-rural disparities during 2017-2019 were evaluated using the Gini coefficient and an unpaired t-test. Correlation was assessed using Pearson's correlation method. The national annual average incidences of lung cancer and lung cancer surgery were 121,106 and 50,959, respectively, in 2014-2019. The use of the thoracoscopic approach increased over time in all procedures, except pneumonectomies. The Gini coefficients of lung cancer, thoracoscopic surgery, and board-certified thoracic surgeons indicated low inequality across prefectures; however, those of open surgery indicated high inequality. Open surgery was more common in urban areas than in rural areas. The number of thoracoscopic surgeries and board-certified thoracic surgeons by prefecture were moderately correlated. The thoracoscopic approach is becoming more common in lung cancer surgery, with little inter-prefectural regional disparity in the incidence of lung cancer, thoracoscopic surgeries, or the number of board-certified thoracic surgeons.

Surgical Technique And Clinical Implications Of Transcatheter Aortic Valve Bioprosthesis Explantation.

There has been a worldwide rapid adoption of transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis. Currently, more TAVR explants with SAVRs are performed than TAVR-in TAV. TAVR explantation is a technically hazardous procedure mainly due to significant aortic neo-endothelialization which incorporates the TAVR valve. Surgical techniques for TAVR explantation are not well established and surgeon experience at present is limited. In this manuscript, we describe our technique for surgical explantation of transcatheter aortic bioprosthesis. Familiarity with the procedure and its clinical implications is essential for all cardiac surgeons.

A National Analysis of Alcohol Withdrawal Syndrome in Patients with Operative Trauma

BackgroundAlcohol withdrawal syndrome (AWS) presents with a complex spectrum of clinical manifestations that complicate postoperative management. In trauma setting, subjective screening for AWS remains challenging due to the criticality of injury in these patients. We thus identified several patient characteristics and perioperative outcomes associated AWS development. MethodsThe 2016–2020 National Inpatient Sample was queried to identify all non-elective adult (≥18 years) hospitalizations for blunt or penetrating trauma undergoing operative management with a diagnosis of AWS. Patients with traumatic brain injury or with a hospital duration of stay <2 days were excluded. Outcomes of interest included in-hospital mortality, perioperative complications, hospitalization costs, length of stay (LOS) and non-home discharge. ResultsOf an estimated 2,965,079 operative trauma hospitalizations included for analysis, 36,415 (1.23 %) developed AWS following admission. The AWS cohort demonstrated increased odds of mortality (Adjusted Odds Ratio [AOR] 1.46, 95 % Confidence Interval [95 % CI] 1.23–1.73), along with infectious (AOR 1.73, 95 % CI 1.58–1.88), cardiac (AOR 1.24, 95 % CI 1.06–1.46), and respiratory (AOR 1.96, 95 % CI 1.81–2.11) complications. AWS was associated with prolonged LOS, (β: 3.3 days, 95 % CI: 3.0 to 3.5), greater cost (β: +$8900, 95 % CI $7900–9800) and incremental odds of nonhome discharge (AOR 1.43, 95 % CI 1.34–1.53). Furthermore, male sex, Medicaid insurance status, head injury and thoracic operation were linked with greater odds of development of AWS. ConclusionIn the present study, AWS development was associated with increased odds of in-hospital mortality, perioperative complications, and resource burden. The identification of patient and operative characteristics linked with AWS may improve screening protocols in trauma care.

Ten-year Durability, Hemodynamic Performance, and Clinical Outcomes after Transcatheter Aortic Valve Implantation Using a Self-expanding Device.

The expansion of transcatheter aortic valve implantation (TAVI) to low-risk and younger patients has increased the relevance of the long-term durability of transcatheter heart valves (THV). The present study aims to assess the 10-year durability, hemodynamic performance, and clinical outcomes after TAVI using the CoreValve system. An analysis from a prospective registry with predefined clinical and echocardiographic follow-up included 302 patients who underwent TAVI with the CoreValve system between 2007 and 2015. Bioprosthetic valve failure (BVF) was defined as any bioprosthetic valve dysfunction-related death, re-intervention, or severe hemodynamic valve deterioration. At the time of TAVI, the mean age was 80.41 ± 7.01years, and the Society of Thoracic Surgeons (STS) score was 6.13 ± 5.23%. At latest follow-up (median [IQR]: 5 [2-7] years), cumulative all-cause mortality ratesat 3, 5, 7, and 10years was 23.7%, 40%, 65.8%, and 89.8%, respectively. Mean aortic valve area and transvalvular gradient post-TAVI and at 5, 7, and 10years were 1.94, 1.87, 1.69, and 1.98 cm2 (p = 0.236) and 8.3, 9.0, 8.2, and 10.1mmHg (p = 0.796), respectively. Overall, 11 patients had BVF, of whom six had structural valve deterioration (SVD). The 10-year actual and actuarial freedom from BVF was 96.1% and 78.8%, and from SVD was 97.9% and 80.9%, respectively. Three patients developed significant non-SVD due to severe paravalvular leakage, and two patients were diagnosed with infective endocarditis. Using an early-generation self-expanding bioprosthesis, we documented durable hemodynamic performance and low rates of BVF and SVD up to 10 years after TAVI.

Same evidence different recommendations: a methodological assessment of transatlantic guidelines for the management of valvular heart disease.

To identify methodological variations leading to varied recommendations between the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) valvular heart disease (VHD) Guidelines, and to suggest foundational steps towards standardizing guideline development. An in-depth analysis was conducted to evaluate the methodologies used in developing the Transatlantic Guidelines for managing VHD. The evaluation was benchmarked against the standards proposed by the Institute of Medicine. Substantial discrepancies were noted in the methodologies utilized in development processes, including writing committee composition, evidence evaluation, conflict of interest management, and voting processes. Furthermore, despite their mutual differences, both methodologies also demonstrate notable deviations from the IOM standards in several essential areas, including literature review and evidence grading. These dual variances likely influenced divergent treatment recommendations. For example, the ESC/EACTS recommends transcatheter edge-to-edge repair (TEER) for patients ineligible for mitral valve surgery, while the ACC/AHA recommends TEER based on anatomy, regardless of surgical risk. ESC/EACTS guidelines recommend a mechanical aortic prosthesis for patients under 60, while ACC/AHA guidelines recommend it for patients under 50. Notably, the ACC/AHA and ESC/EACTS guidelines have differing age cut-offs for surgical over transcatheter aortic valve replacement (<65 and <75 years, respectively). Variations in methodologies for developing CPGs have resulted in different treatment recommendations that may significantly impact global practice patterns. Standardization of essential processes is vital to increase the uniformity and credibility of CPGs, ultimately improving healthcare quality, reducing variability and enhancing trust in modern medicine.

A rare clinical case of malignant ectopic retrosternal goiter of a large size in a patient with aberrant right subclavian artery

Background. Ectopic goiter accounts for only 0.2 % to 1 % of all mediastinal goiters. The aberrant right subclavian artery (arteria lusoria) is an extremely rare anomaly of the major vessel, with a prevalence not exceeding 0.3 % in the general population. This paper presents the first case of malignant ectopic retrosternal goiter of a large size in combination with the aberrant right subclavian artery. Clinical case description. A 61-year-old male presented to the thoracic surgery department of P. Herzen Moscow oncology Research institute with a large posterior mediastinal mass measuring 108×106×79 mm and adjacent to the right lobe of the thyroid gland. The tumor displaced the trachea and esophagus. Open biopsy through a thoracotomy incision revealed thyroid gland cells without signs of atypia. A detailed examination revealed mediastinal vascular anomaly – retrotracheal position of the right subclavian artery. a complete longitudinal sternotomy, complemented by a right-sided thoracotomy at the 3rd intercostal space, served as the surgical approach. The operation lasted 320 minutes, with a blood loss of 3500 ml. The postoperative period was uneventful. The morphological examination of the surgical specimen revealed nodular hyperplasia of the ectopic thyroid tissue with the growth of well-differentiated follicular carcinoma without metastatic involvement of removed lymph nodes. Considering the identified follicular carcinoma, total thyroidectomy was performed. Conclusion. In surgical planning, it is crucial to assess the location of major mediastinal vessels and their relationship with the goiter. Therefore, all patients with mediastinal lesions should undergo preoperative contrast-enhanced ct. Retrosternal goiter predisposes to a higher rate of malignancy compared to cervical goiter. If the lower edge of the goiter is at the level of or below the aortic arch, cervical access should be supplemented with sternotomy. In cases of a massive thoracic component, additional thoracotomy is justified.

Insight into the research history and trends of total anomalous pulmonary venous connection: a bibliometric analysis

BackgroundTotal anomalous pulmonary venous connection (TAPVC) is a rare congenital heart disease characterized by the inability of all pulmonary veins to connect to the left atrium. Our previous bibliometric article summarized the characteristics of only the 100 most cited papers in TAPVC research. The purpose of this study was to use comprehensive bibliometric analysis to examine the development history, current status, and future trends in the field of TAPVC.MethodsAll publications on TAPVC published between 2000 and 2023 were collected from the Web of Science Core Collection. The publication and citation data were quantitatively analyzed by publication year, country, institution, author, and journal. Co-authorship and co-occurrence analyses were performed using VOSviewer, and keyword and reference bursts were identified using CiteSpace. Pearson’s test was used to examine the correlations between two continuous variables.ResultsAs of July 20, 2023, we identified 368 publications with 3320 citations. These publications were published in 132 journals and authored by 1835 researchers from 457 institutions in 47 countries. For the number of publications, the top country, top institution, top author, and top journals were the United States (n = 82), Shanghai Jiao Tong University (n = 13), Huiwen Chen (n = 9), and Annals of Thoracic Surgery and Pediatric Cardiology (n = 29 each), respectively. For the number of citations, the top country, top affiliation, top author, and top journal were the United States (n = 1348), University of Toronto (n = 250), Christopher A. Caldarone (n = 315), and Annals of Thoracic Surgery (n = 746), respectively. The number of national publications significantly correlated with GDP (R = 0.887, P < 0.001), research & development (R&D) expenditure (R = 0.375, P = 0.013), population (R = 0.694, P < 0.001), and journals (R = 0.751, P < 0.001). The number of national citations significantly correlated with GDP (R = 0.881, P < 0.001), R&D expenditure (R = 0.446, P = 0.003), population (R = 0.305, P = 0.037), and journals (R = 0.917, P < 0.001). International collaboration in the field of TAPVC was not well developed. The most commonly cited publication discussed era changes in mortality and reoperation rate in TAPVC patients. The most common keywords were “total anomalous pulmonary venous connection” and “congenital heart disease”. The keyword “case report” appeared most recently, with an average occurrence year of 2021.8. The co-occurrence analysis grouped 26 keywords into six themes: surgical repair of TAPVC, postoperative pulmonary vein stenosis, surgical repair of TAPVC patients with heterotaxy, application of echocardiography in diagnosing TAPVC, application of echocardiography in the prenatal diagnosis of TAPVC, and application of the sutureless technique in the surgical repair of TAPVC patients with right atrial isomerism or a single ventricle. Citation burst detection identified 32 references with citation bursts, seven of which had ongoing citation bursts until 2023.ConclusionsThis study conducted a bibliometric analysis to provide a comprehensive overview of TAPVC research. We hope to offer new ideas for promoting development in the field of TAPVC.

Assessment of pulmonary vascular anatomy: comparing augmented reality by holograms versus standard CT images/reconstructions using surgical findings as reference standard

BackgroundWe compared computed tomography (CT) images and holograms (HG) to assess the number of arteries of the lung lobes undergoing lobectomy and assessed easiness in interpretation by radiologists and thoracic surgeons with both techniques.MethodsPatients scheduled for lobectomy for lung cancer were prospectively included and underwent CT for staging. A patient-specific three-dimensional model was generated and visualized in an augmented reality setting. One radiologist and one thoracic surgeon evaluated CT images and holograms to count lobar arteries, having as reference standard the number of arteries recorded at surgery. The easiness of vessel identification was graded according to a Likert scale. Wilcoxon signed-rank test and κ statistics were used.ResultsFifty-two patients were prospectively included. The two doctors detected the same number of arteries in 44/52 images (85%) and in 51/52 holograms (98%). The mean difference between the number of artery branches detected by surgery and CT images was 0.31 ± 0.98, whereas it was 0.09 ± 0.37 between surgery and HGs (p = 0.433). In particular, the mean difference in the number of arteries detected in the upper lobes was 0.67 ± 1.08 between surgery and CT images and 0.17 ± 0.46 between surgery and holograms (p = 0.029). Both radiologist and surgeon showed a higher agreement for holograms (κ = 0.99) than for CT (κ = 0.81) and found holograms easier to evaluate than CTs (p < 0.001).ConclusionsAugmented reality by holograms is an effective tool for preoperative vascular anatomy assessment of lungs, especially when evaluating the upper lobes, more prone to anatomical variations.Trial registrationClinicalTrials.gov, NCT04227444Relevance statementPreoperative evaluation of the lung lobe arteries through augmented reality may help the thoracic surgeons to carefully plan a lobectomy, thus contributing to optimize patients’ outcomes.Key points• Preoperative assessment of the lung arteries may help surgical planning.• Lung artery detection by augmented reality was more accurate than that by CT images, particularly for the upper lobes.• The assessment of the lung arterial vessels was easier by using holograms than CT images.Graphical

A New Functional Threshold for Minimally Invasive Lobectomy.

To assess the performance of a lower predicted postoperative (ppo) forced expiratory volume in 1 second (FEV1) or diffusion capacity of the lung for carbon monoxide (DLCO) (ppoFEV1/ppoDLCO) threshold to predict cardiopulmonary complications after minimally invasive surgery (MIS) lobectomy. Although MIS is associated with better postoperative outcomes than open surgery, MIS uses risk-assessment algorithms developed for open surgery. Moreover, several different definitions of cardiopulmonary complications are used for assessment. All patients who underwent MIS lobectomy for clinical stage I-II lung cancer from 2018 to 2022 at our institution were considered. The performance of a ppoFEV1/ppoDLCO threshold of <45% was compared against that of the current guideline threshold of <60%. Three different definitions of cardiopulmonary complications were compared: Society of Thoracic Surgeons (STS), European Society of Thoracic Surgeons (ESTS), and Berry et al. In 946 patients, the ppoFEV1/ppoDLCO threshold of <45% was associated with a higher proportion correctly classified (79% [95% CI, 76%-81%] vs. 65% [95% CI, 62%-68%]; P<0.001). The complication with the biggest difference in incidence between ppoFEV1/ppoDLCO of 45%-60% and >60% was prolonged air leak (33 [13%] vs. 34 [6%]; P<0.001). The predicted probability curves for cardiopulmonary complications were higher for the STS definition than for the ESTS or Berry definitions across ppoFEV1 and ppoDLCO values. The ppoFEV1/ppoDLCO threshold of <45% more accurately classified patients for cardiopulmonary complications after MIS lobectomy, emphasizing the need for updated risk-assessment guidelines for MIS lobectomy to optimize additional cardiopulmonary function evaluation.

Sex and Psychosocial Differences in Acute Stress Symptoms Prior to Open-Heart Surgery.

Acute stress symptoms can occur while cardiac patients await open-heart surgery (OHS). The distress leads to poor outcomes. This study aimed to investigate the association of sex and psychosocial factors (quality-of-life and character strengths). Our study cohort included 481 pre-OHS patients (female 42%; mean age 62 years).Medical indices/factors were obtained from the Society of Thoracic Surgeon's nationaldatabase. Multiple regression analyses were performed following pre-planned stepsand adjusting medical factors. Our findings revealed that sex differences in trauma-related symptoms wereassociated with poor mental well-being, alongside comorbidities. Both mental well-beingand comorbidity factors were directly related to acute stress symptoms, whiledispositional optimism had an inverse association with this outcome. To improve OHS outcomes, our findings suggest healthcare providers be attentive topre-OHS acute stress symptoms, pay greater attention to the emotional well-being oftheir female patients, and develop supportive interventions to enhance personalitystrengths.

Venoarterial ECMO in cardiogenic shock: a decade-long single-center analysis

Abstract Funding Acknowledgements None. Introduction Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) has emerged as a salvage intervention in refractory cardiogenic shock, offering both circulatory and respiratory support as a bridge to recovery, a bridge to transplant, or a bridge to decision. Purpose This study aimed to assess the demographics, clinical characteristics, and outcomes of VA-ECMO patients with cardiogenic shock in a tertiary center. Methods We conducted a retrospective observational study, encompassing patients admitted with cardiogenic shock and treated with VA-ECMO up to October 2023, marking the milestone of the 100th VA-ECMO patient in our unit. Key patient data, including demographics, clinical presentation, ECMO-related complications, and outcomes, were extracted from medical records. Summary statistics were employed for data analysis. Results From 2012 to October 2023, our hospital treated 100 patients in VA-ECMO. The mean age was 58.4 ± 11.9 years, with a male predominance (60%). Approximately 50% of patients were admitted from the emergency room after sudden cardiac arrest. Acute coronary syndrome (ACS) accounted for 39% of cardiogenic shock cases, followed by complicated post-valvular replacement surgery (13%), myocarditis (10%), and acute decompensated heart failure (9%). The median hospital stay was 12.5 days (range: 0 to 114), with a median of 4.0 days on ECMO (range: 0 to 52). All VA-ECMO reported in this cohort were percutaneous, with 39% requiring left ventricular unloading. In 11% cases VA-ECMO served as a bridge to transplant. When it comes to VA-ECMO-related complications, hematological complications, including anemia and thrombocytopenia necessitating transfusion, were observed in 53% of patients, and thromboembolic complications, such as acute limb ischemia, affected 28% of patients. Bleeding complications were notable, with 12% experiencing significant access bleeding, 16% gastrointestinal bleeding, 9% airway bleeding, and 2% intracerebral hemorrhage. Additionally, 39% necessitated renal replacement therapy due to acute kidney failure. The 5-day survival rate stood at 69% (95% CI, 0.61-0.79), declining to 36% at 30 days (95% CI, 0.27-0.48) (see Figure 1). Of the 100 patients, 41 died while on VA-ECMO, with 36 either discharged or undergoing transplantation. Conclusions Our single-center experience illustrates VA-ECMO's predominant use in younger patients following ACS or cardiothoracic surgery. Despite associated complications, particularly thromboembolic events and severe bleeding, our observed mortality rate is slightly lower than reported for refractory cardiogenic shock. New research has emerged from global VA-ECMO registries, as well as clinical trials, however real-world data is lacking. This analysis provides a foundational understanding of cohort characteristics and sets the stage for future comparative studies.Table 1.Patient CharacteristicsFigure 1.Surviving Curve

Impact of acute aortic pathology care process reengineering on mortality of type A acute aortic syndrome

Abstract Funding Acknowledgements None. Introduction Type A Acute aortic syndrome (AAS) is a life-threatening disease. Although emergent surgery is the treatment of choice, these procedures are highly complex and require a high level of expertise. Process reengineering has demonstrated prognostic benefit in acute cardiovascular pathology. Purpose The aim of the present work is to assess whether the reorganization of AAS care has an impact on patient prognosis. Methods The "Aorta Code" (AC) is a protocol for AAS-patients’ care within a network of 4 hospitals with a tertiary hospital as a referral center. A common diagnostic algorithm was specifically designed and periodical training programs were carried out in the different emergency departments at the 4 hospitals. Once activated, the out of hospital emergency service immediately transfers the patient to the Acute Cardiovascular Care Unit at the referral center. An Aortic Dissection Team was responsible for patients’ care. Only two cardiac surgeons and two vascular surgeons performed all AAS surgeries. All patients with AAS were prospectively and consecutively collected and patients with type A AAS were selected for analysis. Expected 30-day mortality was calculated using the GERAADA score. Results From April-2019 to April-2023, 113 patients with AAS were included. Of them, 75.9% (83) were type A. 12% (10) of the patients died before reaching the operating theatre. In 9% (8) of the sample, surgery was rejected due to comorbidities and unacceptable surgical risk, of whom 4 patients died. Mean age was 66.7±13.7 years and 71% were males. Patients with type A AAS presented a significant burden of pre-surgical complications: severe aortic regurgitation (35.6%), cardiac tamponade (26.8%), shock (32.9%), cardiorespiratory arrest (8.5%), need for intubation (26.8%), acute renal failure (27%), peripheral malperfusion (12.7%) and myocardial ischemia (9.52%). Although the AC included a high risk AAS population, the process reorganization, and concentration of patients’ care in an experienced medical and surgical team resulted in a significant reduction of surgical mortality of patients with type A AAS compared to the expected mortality based on risk (figure). Conclusion AAS process reengineering and concentration of AAS management in an experienced medical-surgical team is associated with an improvement in the expected prognosis and mortality.Pre-surgical type A AAS complications.

Practice Patterns in Sternal Closure and Evaluation of Adoption of a Novel Sternal Closure Device

Objective: The technique for sternal closure has remained largely unchanged owing to the efficacy, simplicity, and low cost of stainless-steel sternal wires. Despite their ubiquity, several other closure devices designed to address the complications associated with sternal wires such as sternal bleeding and dehiscence have become popular. We have developed a novel sternal closure device that reduces sternal bleeding and dehiscence. This study quantifies the use of currently available sternal closure devices and determines predicted uptake of the novel device. Methods: An electronic survey, designed to determine practice patterns for sternal closure, was distributed to 70 US cardiac surgeons. The survey included a discrete choice section in which surgeons evaluated relative value of device attributes including cost, ease of emergent sternal reentry, and dehiscence risk. Results: There were 70 surgeons from 30 states who completed the survey. The most frequent means of sternal closure was straight sternal wires (35.8%), followed by straight sternal wires plus figure-of-8 sternal wires (18.1%), double wires (10.9%), plates (10.2%), and other (25%). The relative utilization shifted from sternal wires to sternal plates as the risk for dehiscence increased. The adoption of the novel closure device was estimated at 34.6%. Conclusions: The standard stainless-steel sternal wire remains the most common means of sternal reapproximation, but its utilization is lower in patients at high risk for sternal dehiscence. Based on this survey, there is acceptance in the community for a novel sternal closure device designed to address the limitations of traditional sternal closure methods.

Procedural Results and Long-term Outcome of Chronic Total Occlusion Percutaneous Coronary Intervention in a UK Non-surgical Centre.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved a great deal over recent years, with increased procedural success and lower complication rates being reported. This study aims to evaluate the feasibility, safety and success of a dedicated CTO programme in a large UK PCI centre without on-site cardiothoracic surgery facilities. Clinical and procedural data were retrospectively collected for consecutive unselected patients undergoing CTO PCI between 2015 and 2019 from the local database and regional electronic patient records. In-hospital outcomes and long-term major adverse cardiovascular events (all-cause mortality, MI, stroke and target vessel revascularisation) were recorded. A total of 170 patients underwent 191 CTO procedures during the study period. The mean age was 63 ± 10 years and 80.6% of patients were male (n=137). The clinical indications were: stable chronic coronary syndromes in 88.5% (n=169) of patients; staged procedures in the context of acute coronary syndromes in 1.6% (n=3); and presentation with acute coronary syndrome in 9.9% (n=19). The procedural success rate was 50.0% (n=25) for general interventional cardiologists and 90.1% (n=127) for dedicated CTO operators. In-hospital major adverse cardiovascular events occurred once (0.5%) and interhospital transfer for emergency salvage cardiac surgery was not required. Long-term follow-up data at a median duration of 3.8 years revealed 4 (2.4%) cardiac deaths, 14 (8.3%) spontaneous MI events and 10 (5.9%) target vessel revascularisations. These data suggest CTO PCI using contemporary techniques is both safe and effective when undertaken in a high-volume non-surgical centre by experienced operators.

Weight loss, glycolipid profile changes in type 2 diabetes patients after esophagectomy: a propensity score matching analysis

BackgroundType 2 diabetes mellitus (T2DM) is a common co-morbidity in patients who receive esophagectomy and has unfavorable effects on glucose and lipid metabolism in patients. This study examines how weight and glycolipid metabolism change in patients with T2DM following esophagectomy.MethodsThis retrospective, one-center, observational analysis with a propensity score matching analysis (PSM) included 114 patients who underwent esophageal surgery in the Department of Cardiothoracic Surgery, the 900th Hospital of Joint Logistic Support Force from 2017 to 2020, which were separated into T2DM group and Non-T2DM group. Weight, body mass index (BMI), fasting plasma glucose (FPG), triglycerides (TG), total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) were measured and analyzed before and after the operation.ResultsTwo groups showed similar reductions in weight and BMI after surgery. In the T2DM group, weight decreased from 63.10(10.31) before surgery to 55.10(11.60) kg at 6 months (P < 0.001) with BMI decreasing from 22.67 (2.90) to 19.77 (3.48); While in the Non-T2DM group, weight decreased from 61.42 (8.46) to 53.19 (9.26) kg at 6 months after surgery with BMI decline from 22.49 (2.77) before operation to 19.45 (3.08) at 6 months after surgery. Fasting plasma glucose levels showed a significant decrease (P = 0.035) in the T2DM group at a six-month point of 7.00 (2.21) mmol/L compared to preoperative levels of 7.67 (2.32) mmol/L. HDL levels increased significantly in the Non-T2DM group at six months postoperatively at 1.52 (0.05) with P < 0.001 compared to preoperative levels of 1.22(0.04) mmol/L. TG, LDL, and TC levels decreased significantly in both groups from the preoperative to the 6-month point.ConclusionsEsophagectomy induces weight loss in T2DM and Non-T2DM groups, improves long-term glucose metabolism in the T2DM group, and enhances lipid metabolism in both groups. Further research is needed to understand their mechanisms.

Cardiac Sympathetic Denervation as a Treatment for Ventricular Arrhythmias Refractory to Conventional Treatment: A Case Series.

Ventricular arrhythmias are a leading cause of sudden death. The objective of this study was to characterise the results of patients with ventricular arrhythmias refractory to standard medical management, undergoing Video-assisted thoracoscopic cardiac sympathetic denervation (VAT-CSD) during 2012-2022 in Cali, Colombia. This was an observational retrospective study, using the Institutional General Thoracic Surgery Database for patient identification and retrospectively reviewing the clinical charts for data description and analysis. Clinical records of 19 patients who underwent VAT-CSD for ventricular arrhythmia were analysed. The patients were predominantly male (73.7%) with an mean age of 62 years. Ischaemic heart disease was the main underlying condition (52.6%); all individuals had a diagnosis of heart failure, with comorbidities such as hypertension (63.1%), acute MI (57.8%) and diabetes (26.3%) also present. The procedure was performed bilaterally in 89.4% of cases and was successful with minimal perioperative complications. Postoperative follow-up showed improvement in symptoms, including a significant reduction in the number of ICD shocks and emergency department visits. VAT-CSD is a viable, safe and palliative therapeutic option for patients with ventricular arrhythmias who have not responded to conventional treatments, achieving a significant decrease in symptoms with low mortality and perioperative complications.