The latest medical research on Cardiothoracic Surgery
The research magnet gathers the latest research from around the web, based on your specialty area. Below you will find a sample of some of the most recent articles from reputable medical journals about cardiothoracic surgery gathered by our medical AI research bot.
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Request AccessFeatures and outcomes of focal intimal disruption in acute type B intramural hematoma.
Cardiothoracic SurgeryFocal intimal disruption is a risk factor for adverse aorta-related events in acute type B intramural haematoma patients. This study evaluated the impact of focal intimal disruption on overall survival with a selective intervention strategy for large or growing focal intimal disruptions. Additionally, this study evaluated the risk factors associated with the growth of focal intimal disruption.
This retrospective study included all consecutive patients admitted for acute type B intramural haematoma between November 2004 and April 2021. The primary outcome was overall survival. The secondary outcome was cumulative incidence of composite aortic events and the growth of focal intimal disruption. The latter was calculated on centerline-reconstructed computed tomography images.
A total of 105 patients were included. A total of 106 focal intimal disruptions were identified in 73 patients (73/105, 69.5%). The 1- and 5-year cumulative incidence rates of composite aortic events were 36.2% and 39.2%, respectively. The 1- and 5-year overall survival were 93.3% and 81.5%, respectively. Initial maximal aortic diameter and large focal intimal disruption during acute phase were significant risk factors for composite aortic event, but not risk factors for overall survival. Early appearance interval of focal intimal disruption was a significant risk factor for growth of focal intimal disruption.
With a selective intervention strategy for large or growing focal intimal disruptions, the presence of large focal intimal disruption during acute phase does not affect overall survival. Early appearance interval was associated with the growth of focal intimal disruption.
Same evidence different recommendations: a methodological assessment of transatlantic guidelines for the management of valvular heart disease.
Cardiothoracic SurgeryTo 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.
Multicentric experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases.
Cardiothoracic SurgeryAim of this multicentre retrospective cohort study is to evaluate technical success, early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside-down through antegrade access, to treat thoracic aortic diseases.
Antegrade TEVAR performed between January 2010 and December 2021 have been collected and analyzed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed into previous or concomitant surgical or endovascular repairs.
Fourteen patients were enrolled; 13 males (94%) with mean age of 71 years (IQR 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indication to treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (IQR 1; 44). Late death occurred in 2 (20%) patients, both operated in elective setting. The first died at 19 months due to aortic-related reintervention, the second died at 34 months for a not aortic-related cause. Two patients (14%) underwent aortic-related reintervention for late type I endoleak. Survival rate in elective procedures was 100%, 84% and 67% at 12, 24 and 36 months respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months respectively.
Antegrade TEVAR can seldomly be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and low access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.
Patent ductus arteriosus management in very-low-birth-weight prematurity: a place for early surgery?
Cardiothoracic SurgeryTo evaluate neonatal outcomes based on treatment strategies and time points for haemodynamically significant patent ductus arteriosus (hsPDA) in very-low-birth-weight (VLBW) preterm infants, with a particular focus on surgical closure.
This retrospective study included VLBW infants born between 2014 and 2021, received active treatment for hsPDA. Neonatal outcomes were compared between: (1) primary surgical closure vs primary ibuprofen, (2) early (<14th post-natal day) vs late primary surgical closure (≥14th post-natal day), and (3) primary vs secondary surgical closure after ibuprofen failure. Further analysis using 1:1 propensity score matching was performed. Logistic regression was conducted to analyze the risk factors for post-ligation cardiac syndrome (PLCS) and/or acute kidney injury (AKI).
A total of 145 hsPDA infants underwent active treatment for closure. In-hospital death rate and severe bronchopulmonary dysplasia (BPD) were similar between the primary surgical closure group and primary ibuprofen group in 1:1 matched analysis. Severe BPD was significantly higher in late surgical closure group than in early primary surgical closure group with 1:1 propensity score matching (72.7% vs 40.9%, p=0.033). The secondary surgical closure group showed the mildest clinical condition, however, the probability of PLCS/AKI was highest (38.6%), compared to early (15.2%) or late primary surgical group (28.1%, p<0.001) especially in extremely premature infants (gestational age <28weeks).
Surgical PDA closure is not inferior to pharmacological treatment. Timely decision and efforts should be made considering the harmful effect of prolonged PDA shunt exposure to minimize the risk of severe BPD and PLCS/AKI after surgical closure.
Open, endovascular, or hybrid repair of aortic arch disease: narrative review of diverse strategies with diverse options.
Cardiothoracic SurgeryThe management of aortic arch disease is complex. Open surgical management continues to evolve, and the introduction of endovascular repair is revolutionizing aortic arch surgery. Although these innovative techniques have generated the opportunity for better outcomes in select patients, they have also introduced confusion and uncertainty regarding best practices. In New York, we have developed a collaborative group named the New York Aortic Consortium (NYAC) as a means of crosslinking knowledge and working together to better understand and treat aortic disease. In our meeting in May 2023, regional aortic experts and invited international experts discussed the contemporary management of aortic arch disease, differences in interpretation of the available literature, as well as the integration of endovascular technology into disease management. In this review article, we summarize the current state of aortic arch surgery.
Approaches to aortic arch repair have evolved substantially, whether it be methods to reduce cerebral ischaemia, improve hemostasis, simplify future operations, or expand options for high-risk patients with endovascular approaches. However, the transverse aortic arch remains challenging to repair. Amongst our collaborative group of cardiac/aortic surgeons, we discovered a wide disparity in our practice patterns and management strategies of patients with aortic arch disease.
It is important to build unique institutional expertise in the context of complex and evolving management of aortic arch disease with open surgery, endovascular repair, and hybrid approaches, tailored to the risk profiles and anatomical specifics of individual patients.
Identifying Population-Level and Within-Hospital Disparities in Surgical Care.
Journal of theThe lack of consensus on equity measurement and its incorporation into quality-assessment programs at the hospital and system levels may be a barrier to addressing disparities in surgical care. This study aimed to identify population-level and within-hospital differences in the quality of surgical care provision.
The analysis included 657 National Surgical Quality Improvement Program participating hospitals with over 4 million patients (2014-2018). Multi-level random slope, random intercept modeling was used to examine for population-level and in-hospital disparities. Disparities in surgical care by Area Deprivation Index (ADI), race, and ethnicity were analyzed for five measures: all-case inpatient mortality, all-case urgent readmission, all-case postoperative surgical site infection, colectomy mortality, and spine surgery complications.
Population-level disparities were identified across all measures by ADI, two measures for Black race (all-case readmissions and spine surgery complications), and none for Hispanic ethnicity. Disparities remained significant in the adjusted models. Prior to risk-adjustment, in all measures examined, within-hospital disparities were detected in: 25.8-99.8% of hospitals for ADI, 0-6.1% of hospitals for Black race, and 0-0.8% of hospitals for Hispanic ethnicity. Following risk-adjustment, in all measures examined, fewer than 1.1% of hospitals demonstrated disparities by ADI, race, or ethnicity.
Following risk adjustment, very few hospitals demonstrated significant disparities in care. Disparities were more frequently detected by ADI than by race and ethnicity. The lack of substantial in-hospital disparities may be due to the use of postoperative metrics, small sample sizes, the risk adjustment methodology, and healthcare segregation. Further work should examine surgical access and healthcare segregation.
Return to work and activity after rib-fixation for acute chest trauma: first application of a validated patient-reported outcomes assessment tool.
Cardiothoracic SurgeryRib fractures present a heavy pain and functional burden in trauma. Our primary aim was to determine return to work in patients with acute rib fractures requiring surgical stabilisation of rib fractures. Our secondary outcomes were pain and quality of life. We also document the first application of the Work Productivity and Activity Impairment Instrument, a validated injury-specific patient-reported outcome measure, for chest wall injury in the literature.
A retrospective review was conducted of patients with rib fractures requiring surgical fixation in a single centre between 2008-2020. After applying inclusion and exclusion criteria to ensure relevance, all eligible patients were asked to complete patient reported outcome measure questionnaires.
Of 1841 trauma patients with rib fractures, 66 underwent surgical fixation. Thirty-nine patients were eligible and thirty-one completed the questionnaires. Pre-injury and post-injury answers were compared. The number of patients in employment decreased post-operatively from 22 to 16 (p = 0.006). For those that returned to work there was no difference in hours missed but reduced weekly hours and productivity scores. There were significantly more patients with pain and on pain relief. There was a lower quality of life score post-operatively.
Approximately 1-in-5 patients who require surgical fixation for rib fractures will not return to work. This is the first chest wall trauma study that uses the Work Productivity and Activity Impairment Instrument, a validated tool for work productivity outcomes. We recommend this instrument as a reliable tool for investigating return to work outcomes in trauma patients.
Thirty- and 90-Day Morbidity and Mortality by Clavien-Dindo 30 and 90 Days after Surgery for Antireflux and Hiatal Hernia.
Journal of theThe historic morbidity and mortality rates of anti-reflux and hiatal hernia surgery are reported as 3-21% and 0.2-0.5%, respectively. These data come from either large national/population level or small institutional studies, with the former focusing on broad 30-day outcomes while lacking granular data on complications and their severity. Institutional studies tend to focus on long-term and quality of life outcomes. Our objective is to describe and evaluate the incidence of 30 and 90-day morbidity and mortality in a large, single institution dataset.
We retrospectively reviewed 2342 cases of anti-reflux and hiatal hernia surgery from 2003-2020 for intra-operative complications causing post-operative sequelae, as well as morbidity and mortality within 90 days. All complications were graded using the Clavien-Dindo (CD) Grading System. The highest-grade of complication was used per patient during 30-day and 31-90-day intervals.
Out of 2342 patients, the overall 30-day morbidity and mortality rates were 18.2% (427/2342) and 0.2% (4/2342), respectively. Most of the complications were CD<3a at 13.1% (306/2342). In the 31-90-day post-operative period, morbidity and mortality rates decreased to 3.1% (78/2338) and 0.09% (2/2338). CD<3a complications accounted for 1.9% (42/2338).
Anti-reflux and hiatal hernia surgery are safe operations with rare mortality and modest rates of morbidity. However, the majority of complications patients experience are minor (CD<3a) and are easily managed. A minority of patients will experience major complications (CD≥3a) that require additional procedures and management to secure a safe outcome. These data are helpful to inform patients of the risks of surgery, and guide physicians for optimal consent.
Impostor Phenomenon and Impact on Women Surgeons: A Canadian Cross-Sectional Survey.
Journal of theThis project aims to characterize the extent and nature of IP among women surgeons in Canada. Impostor Phenomenon (IP) is well documented among medical professionals and trainees. It is known to have significant impacts on mental health and career trajectory.
We conducted a cross-sectional survey of self-identifying women who have completed a surgical residency and currently or most recently practiced in Canada.
Among 387 respondents, 98.7% have experienced IP. Median IP score corresponded to frequent impostor feelings or high impostorism. Self-doubt affects most women surgeons for the first time during training. It tends to be most intense in the first 5 years of practice and lessens over time. 112 surgeons (31.5%) experience self-doubt in the OR. Due to self-doubt, 110 respondents (28.4%) preferred to work with a more experienced assistant in the OR, while 40 (10.4%) stated that they would only operate with an experienced assistant. Few surgeons take on less OR time due to self-doubt (29 (7.5%)) but 60 (16.5%) take on less complex cases due to self-doubt. A small but important number of surgeons (11 (2.8%)) had given up operating altogether due to self-doubt. Due to feelings of self-doubt, 107 (21.4%) were hesitant to take on a leadership role in the workplace.
IP is a nearly universal experience among women surgeons and is influential in their professional lives. This study contributes to scientific knowledge that can advance gender equity in medicine and leadership.
Examining the typical hemodynamic performance of nearly 3000 modern surgical aortic bioprostheses.
Cardiothoracic SurgeryThe objective of this analysis was to assess the normal haemodynamic performance of contemporary surgical aortic valves at 1 year postimplant in patients undergoing surgical aortic valve replacement (SAVR) for significant valvular dysfunction. By pooling data from four multicentre studies, this study will contribute to a better understanding of the effectiveness of SAVR procedures, aiding clinicians and researchers in making informed decisions regarding valve selection and patient management.
Echocardiograms were assessed by a single core laboratory. Effective orifice area (EOA), dimensionless velocity index (DVI), mean aortic gradient, peak aortic velocity, and stroke volume were evaluated.
The cohort included 2958 patients. Baseline age in the studies ranged from 70.1 ± 9.0 to 83.3 ± 6.4 years, and STS risk of mortality was 1.9 ± 0.7 to 7.5 ± 3.4%. Twenty patients who had received a valve model implanted in fewer than 10 cases were excluded. Ten valve models (all tissue valves; N = 2938 patients) were analyzed. At 1 year, population mean EOA ranged from 1.46 ± 0.34 to 2.12 ± 0.59 cm2, and DVI, from 0.39 ± 0.07 to 0.56 ± 0.15. The mean gradient ranged from 8.6 ± 3.4 to 16.1 ± 6.2 mmHg with peak aortic velocity of 1.96 ± 0.39 to 2.65 ± 0.47 m/s. Stroke volume was 75.3 ± 19.6 to 89.8 ± 24.3 mL.
This pooled cohort is the largest to date of contemporary surgical aortic valves with echocardiograms analyzed by a single core lab. Overall haemodynamic performance at 1 year ranged from good to excellent. These data can serve as a benchmark for other studies and may be useful to evaluate the performance of bioprosthetic surgical valves over time.
Aerostasis to limit air-leak following extended pleurectomy-decortication.
Cardiothoracic SurgeryExtended pleurectomy-decortication is a cytoreductive surgical treatment for malignant pleural mesothelioma. Prolonged air-leak remains a major pos...
Drivers of Variation in Opioid Prescribing after Common Surgical Procedures in a Large Multihospital Healthcare System.
Journal of theMisuse of prescription opioids is a well-established contributor to the United States opioid epidemic. The primary objective of this study was to identify which level of care delivery (i.e. patient, prescriber, or hospital) produced the most unwarranted variation in opioid prescribing after common surgical procedures.
Electronic health record (EHR) data from a large multihospital healthcare system was used in conjunction with random-effect models to examine variation in opioid prescribing practices following similar inpatient and outpatient surgical procedures between October 2019 and September 2021. Unwarranted variation was conceptualized as variation resulting from prescriber behavior unsupported by evidence. Covariates identified as drivers of warranted variation included characteristics known to influence pain levels or patient safety. All other model variables, including prescriber specialty and patient race, ethnicity, and insurance status were characterized as potential drivers of unwarranted variation.
Among 25,188 procedures with an opioid prescription at hospital discharge, 53.5% exceeded guideline recommendations, corresponding to 13,228 patients receiving the equivalent of >140,000 excess 5mg oxycodone tablets following surgical procedures. Prescribing variation was primarily driven by prescriber-level factors, with approximately half of the total variation in morphine milligram equivalents (MMEs) prescribed observed at the prescriber level and not explained by any measured variables. Unwarranted covariates associated with higher prescribed opioid quantity included non-Hispanic black race, Medicare insurance, smoking history, later hospital discharge times, and prescription by a surgeon rather than a hospitalist or primary care provider.
Given the large proportion of unexplained variation observed at the provider level, targeting prescribers through education and training may be an effective strategy for reducing postoperative opioid prescribing.
