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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Totally endoscopic aortic valve replacement via an anterolateral approach using a standard prosthesis.

Interactive Cardiovascular and Thoracic Surgery

Totally endoscopic aortic valve replacement (AVR) is still a challenging operation, and only a few series reports exist in the literature. The purposes of this study were to establish a method for endoscopic AVR and evaluate its initial results.

A total of 47 patients (median age 76 years, 17 men) underwent endoscopic AVR. The main wound was created in the right anterolateral 4th intercostal space through a 4-cm skin incision. No rib spreader was used. A 3-dimensional endoscope was inserted at the midaxillary line. A 5.5-mm trocar was inserted in the 3rd intercostal space, thus creating a 3-port setting similar to that used for endoscopic mitral valve surgery. A standard prosthesis was used, and the sutures were tied using a knot pusher. Results were compared with those of 157 patients who underwent right transaxillary AVR with direct vision plus endoscopic assist.

Patient backgrounds did not differ significantly between the 2 groups. No deaths occurred in the entire series. There was no conversion to thoracotomy or sternotomy in the endoscopic AVR group. The complication rate did not differ significantly between the 2 groups. The total operating time was significantly shorter in endoscopic AVR (188-206 min); the cardiopulmonary bypass time (130-128 min) and the cross-clamp time (90-95 min) did not differ significantly (median, endoscopic AVR, right transaxillary AVR). Two patients underwent endoscopic double-valve (aortic and mitral) surgery under the same conditions.

Endoscopic AVR was possible through 3 ports created in the right anterolateral chest, similar to the procedure for endoscopic mitral valve surgery. By adopting a common approach for both the aortic and the mitral valve operations, endoscopic double-valve surgery can be performed seamlessly.

Comparison of aortic remodelling after conservative treatment or thoracic endovascular repair in type B dissections.

Interactive Cardiovascular and Thoracic Surgery

Our aim was to compare aortic remodelling in type B dissections after thoracic endovascular aortic repair (TEVAR) or conservative treatment.

We conducted a retrospective analysis of computed tomography (CT) data sets at dissection onset and at the last follow-up in a group with conservative (group A) and TEVAR treatment (group B). An additional analysis of the preoperative CT images was performed in patients from group A, who were converted to TEVAR during follow-up. Diameters and lengths of all aortic segments were measured and growth rates were calculated.

We included 74 patients: 50 patients in group A (follow-up time: 1625 ± 209 days) and 24 patients in group B (follow-up time: 554 ± 129 days). The mean aortic diameter growth rate was significantly higher in group A than in group B in the mid-descending aorta (A: +7 mm/year; B: -4 mm/year; P = 0.003). Length growth difference was only present in the abdominal aortic segment and was more pronounced in group A (+2 vs ±0 mm/year; P = 0.009). The conversion rate from conservative treatment to TEVAR was 36% (n = 18). A false lumen diameter of >22 mm at baseline was associated with a higher rate of conversion (P = 0.036). After conversion, the mean growth rate in the proximal descending and mid-descending aorta decreased from preoperative +11 and +18 mm/year to postoperative -9 and -14 mm/year, respectively (P < 0.001).

In acute type B dissections, TEVAR stops aortic enlargement in the thoracic aorta, but promotes distal dilatation compared to the conservative treatment group. After conversion to TEVAR in conservatively pretreated chronic type B dissections, a more pronounced diameter decrease in the descending aorta was observed than in patients treated in the acute phase.

Outcome of video-assisted thoracoscopic implantation of epicardial left ventricular leads with visual targeting for cardiac resynchronization therapy.

Interactive Cardiovascular and Thoracic Surgery

Our goal was to analyse the implantation and outcome of thoracoscopic epicardial leads after a failed endovascular approach or follow-up (FU) complications after endovascular implantation.

We reviewed the records of patients with failed endovascular left ventricular (LV) lead placement or complications during FU, who were subsequently referred to cardiac surgeons for treatment with thoracoscopic LV lead implantation. We analysed the reasons for endovascular failure; the indications for the surgical procedures; and the clinical, echocardiographic and device FU results.

Between 2010 and 2013, a total of 23 patients were included. Among them, 17 of the patients had no previous cardiothoracic surgery, 13 (76%) had successful video-assisted thoracoscopy (VAT) LV lead implantation, 3 (18%) had a conversion to thoracotomy and 1 (6%) failed. Of the 6 patients with prior cardiothoracic surgery, 2 (33%) had VAT only, 3 (50%) had primary thoracotomies and 1 (17%) had a conversion. Two major complications occurred. The reasons for LV endovascular lead failure were subclavian vein occlusion (n = 2), implant failure (n = 13) and complications during the FU period (n = 8). FU information was available for 20 patients: 17 (85%) had improved symptoms. The median FU period was 33 months. A total of 78% of patients were in New York Heart Association (NYHA) functional class III-IV before the operation; 30% were in NYHA functional class III-IV at the last FU examination. The left ventricular ejection fraction increased from 25% before surgery to 31% at the last FU examination. Overall, sensing and pacing threshold values remained stable over time. In 1 patient, lead revision was necessary due to an increase in the pacing threshold.

VAT implantation of LV leads had an excellent response rate with an improvement in NYHA functional class and left ventricular ejection fraction. The lead measurements were mainly stable over time.

Association of Treatment Inequity and Ancestry With Pancreatic Ductal Adenocarcinoma Survival.

JAMA Surgery

Pancreatic ductal adenocarcinoma (PDAC) has a higher incidence and worse outcomes among black patients than white patients, potentially owing to a combination of socioeconomic, biological, and treatment differences. The role that these differences play remains unknown.

To determine the level of survival disparity between black and white patients in a modern PDAC cohort and whether treatment inequity is associated with such a disparity.

This cohort study used data on 278 936 patients with PDAC with database-defined race from the National Cancer Database from January 1, 2004, to December 31, 2015. The median follow-up for censored patients was 24 months. The National Cancer Database, comprising academic and community facilities, includes about 70% of new cancer diagnoses in the United States. Race-stratified receipt of therapy was the primary variable of interest. Multivariable analyses included additional demographic and clinical parameters. Data analysis was initially completed on November 30, 2018, and revised data analysis was completed on June 27, 2019.

Overall survival was the primary outcome, analyzed with Kaplan-Meier and multivariable Cox proportional hazards regression modeling.

The cohort included 278 936 patients (137 121 women and 141 815 men; mean [SD] age, 68.72 [11.57] years); after excluding patients from other racial categories, 243 820 of the 278 936 patients (87.4%) were white and 35 116 of the 278 936 patients (12.6%) were black. Unadjusted median overall survival was longer for white patients than for black patients (6.6 vs 6.0 months; P < .001). Black patients presented at younger ages than white patients (15 819 of 35 116 [45.0%] vs 83 846 of 243 820 [34.4%] younger than 65 years; P < .001) and with more advanced disease (20 853 of 31 600 [66.0%] vs 135 317 of 220 224 [61.4%] with stage III or IV disease; P < .001). Black patients received fewer surgical procedures than white patients for potentially resectable stage II disease (4226 of 8097 [52.2%] vs 39 214 of 65 124 [60.2%]; P < .001) and slightly less chemotherapy for advanced disease (2756 of 4067 [67.8%] vs 17 296 of 25 227 [68.6%] for stage III disease [P = .001]; 8208 of 16 104 [51.0%] vs 58 603 of 105 616 [55.5%] for stage IV disease [P < .001]). Decreased survival for black patients persisted in multivariable modeling controlled for sociodemographic parameters (hazard ratio, 1.04 [95% CI, 1.02-1.05]). Conversely, modeling that controlled specifically for clinical parameters such as disease stage and treatment revealed a modest survival advantage (hazard ratio, 0.94 [95% CI, 0.93-0.96]) among black patients. Resection was the factor most strongly associated with overall survival (hazard ratio, 0.39 [95% CI, 0.38-0.39]).

Black patients with PDAC present at younger ages and with more advanced disease than white patients, suggesting that differences in tumor biology may exist. Black patients receive less treatment stage for stage and fewer surgical procedures for resectable cancers than white patients; these findings may be only partly associated with socioeconomic differences. When disease stage and treatment were controlled for, black patients had no decrease in survival.

Association of High Mortality With Postoperative Myocardial Infarction After Major Vascular Surgery Despite Use of Evidence-Based Therapies.

JAMA Surgery

Patients undergoing vascular surgery are at high risk of postoperative myocardial infarction (POMI). Postoperative myocardial infarction is independently associated with significant risk of in-hospital mortality.

To examine the association of patient and procedural characteristics with the risk of POMI after vascular surgery and determine the association of evidence-based therapies with longer-term outcomes.

A retrospective cohort study of prospectively collected data within a statewide quality improvement collaborative database between January 2012 and December 2017. Patient demographics, comorbid conditions, and perioperative medications were captured. Patients were grouped according to occurrence of POMI. Univariate analysis and logistic regression were used to identify factors associated with POMI. The collaborative collects data from private and academic hospitals in Michigan. Patients undergoing major vascular surgery, defined as endovascular aortic aneurysm repair, open abdominal aortic aneurysm, peripheral bypass, carotid endarterectomy, or carotid artery stenting were included. Analysis began December 2018.

The presence of a POMI and 1-year mortality.

Of 26 231 patients identified, 16 989 (65.8%) were men and the overall mean (SD) age was 69.35 (9.89) years. A total of 410 individuals (1.6%) experienced a POMI. Factors associated with higher rates of POMI were age (odds ratio [OR], 1.032 [95% CI, 1.019-1.045]; P < .001), diabetes (OR, 1.514 [95% CI, 1.201-1.907]; P < .001), congestive heart failure (OR, 1.519 [95% CI, 1.163-1.983]; P = .002), valvular disease (OR, 1.447 [95% CI, 1.024-2.046]; P = .04), coronary artery disease (OR, 1.381 [95% CI, 1.058-1.803]; P = .02), and preoperative P2Y12 antagonist use (OR, 1.37 [95% CI, 1.08-1.725]; P = .009). Procedurally, open abdominal aortic aneurysm (OR, 4.53 [95% CI, 2.73-7.517]; P < .001) and peripheral bypass (OR, 2.375 [95% CI, 1.818-3.102]; P < .001) were associated with the highest risk of POMI. After POMI, patients were discharged and received evidence-based therapy with high fidelity, including β-blockade (296 [82.7%]) and antiplatelet therapy (336 [95.7%]). A high portion of patients with POMI were dead at 1 year compared with patients without POMI (113 [37.42%] vs 993 [5.05%]; χ2 = 589.3; P < .001).

Despite high rates of discharge with evidence-based therapies, the long-term burden of POMI is substantial, with a high mortality rate in the following year. Patients with diabetes mellitus, coronary artery disease, congestive heart failure, and valvular disease warrant additional consideration in the preoperative period. Further, aggressive strategies to treat patients who experience a POMI are needed to reduce the risk of postoperative mortality.

Surgical treatment for left ventricular-aortic discontinuity and Gerbode defect with endocarditis.

Interactive Cardiovascular and Thoracic Surgery

An extensive infection of the native aortic or prosthetic valve beyond the aortic annulus could be complicated with various types and degrees of ti...

The association of nodal upstaging with surgical approach and its impact on long-term survival after resection of non-small-cell lung cancer.

European Journal of Heart Failure

Proponents of open thoracotomy (OPEN) and robot-assisted thoracic surgery (RATS) claim its oncological superiority over video-assisted thoracic surgery (VATS) in terms of the accuracy of lymph node staging.

The National Cancer Database was queried for patients with non-small-cell lung cancer (NSCLC) undergoing lobectomy without neoadjuvant therapy from 2010 to 2014. Nodal upstaging rates were compared using a surgical approach. Overall survival adjusted for confounding variables was examined using the Cox proportional hazards model.

A total of 64 676 patients fulfilled the selection criteria. The number of patients who underwent lobectomy by RATS, VATS and OPEN approaches was 5470 (8.5%), 17 545 (27.1%) and 41 661 (64.4%), respectively. The mean number of lymph nodes examined for each of these approaches was 10.9, 11.3 and 10 (P < 0.01) and upstaging rates were 11.2%, 11.7% and 12.6% (P < 0.01), respectively. For patients with clinical stage I disease (N = 46 826; RATS = 4338, VATS = 13 416 and OPEN = 29 072), the mean lymph nodes examined were 10.6, 10.8 and 9.4 (P < 0.01), and upstaging rates were 10.8%, 11.1% and 12.1% (P < 0.01), respectively. A multivariable analysis suggested an association with improved survival with RATS and VATS compared with OPEN surgery [hazard ratio (HR) = 0.89 and 0.89, respectively; P < 0.01] for patients with all stages. In stage I disease, VATS but not RATS was associated with increased overall survival compared with the OPEN approach (HR = 0.81; P < 0.01).

RATS lobectomy is not superior to VATS lobectomy with respect to lymph node yield or upstaging of NSCLC. Increased nodal upstaging by the OPEN approach does not confer a survival advantage in any stage of NSCLC and may be associated with decreased overall survival.

International Delphi survey of the ESTS/AATS/ISTH task force on venous thromboembolism prophylaxis in thoracic surgery: the role of extended post-discharge prophylaxis.

European Journal of Heart Failure

Venous thromboembolic events can be successfully prevented with chemical and/or mechanical prophylaxis measures, but evidence-based guidelines in thoracic surgery are limited, particularly regarding extended post-discharge prophylaxis. This study attempts to gather an international consensus on best practices to inform the development of such guidelines.

A series of 3 surveys was distributed to the ESTS/AATS/ISTH (European Society of Thoracic Surgeons, American Association of Thoracic Surgeons, International Society for Thrombosis and Haemostasis) venous thromboembolic events prophylaxis working group starting January 2017. This iterative Delphi consensus process sought to gather a consensus on (i) risk factors; (ii) preferred agents; (iii) duration; and (iv) perceived barriers to an extended thromboprophylaxis approach. Participant responses were expressed on a 10-point scale, and the results were summarized and circulated to all respondents in subsequent rounds. A coefficient of variance of ≤0.3 was identified pre hoc to identify agreement.

A total of 21 Working Group members completed the surveys, composed of 19% non-surgeon thrombosis experts, and 48% from North America. Respondents largely saw agreement regarding risk factors that indicate a need for extended thromboprophylaxis. The group agreed that low-molecular-weight heparin is a suitable agent for use post-discharge, but there was a wide variety in response regarding agents, duration and barriers to extended prophylaxis, where no consensus was observed across the three rounds.

There is strong agreement around indications for extended venous thromboembolic events thromboprophylaxis after thoracic surgery, but there is little consensus regarding the agents and duration to be employed. Further research is required to better inform guideline development.

Mitochondrial transplantation for myocardial protection in diabetic hearts.

European Journal of Heart Failure

Type 2 diabetes causes mitochondrial dysfunction, which increases myocardial susceptibility to ischaemia-reperfusion injury. We investigated the efficacy of transplantation of mitochondria isolated from diabetic or non-diabetic donors in providing cardioprotection from warm global ischaemia and reperfusion in the diabetic rat heart.

Ex vivo perfused hearts from Zucker diabetic fatty (ZDF fa/fa) rats (n = 6 per group) were subjected to 30 min of warm global ischaemia and 120 min reperfusion. Immediately prior to reperfusion, vehicle alone (VEH) or vehicle containing mitochondria isolated from either ZDF (MTZDF) or non-diabetic Zucker lean (ZL +/?) (MTZL) skeletal muscle were delivered to the coronary arteries via the aortic cannula.

Following 30-min global ischaemia and 120-min reperfusion, left ventricular developed pressure was significantly increased in MTZDF and MTZL groups compared to VEH group (MTZDF: 92.8 ± 5.2 mmHg vs MTZL: 110.7 ± 2.4 mmHg vs VEH: 44.3 ± 5.9 mmHg; P < 0.01 each); and left ventricular end-diastolic pressure was significantly decreased (MTZDF 12.1 ± 1.3 mmHg vs MTZL 8.6 ± 0.8 mmHg vs VEH: 18.6 ± 1.5 mmHg; P = 0.016 for MTZDF vs VEH and P < 0.01 for MTZL vs VEH). Total tissue ATP content was significantly increased in both MT groups compared to VEH group (MTZDF: 18.9 ± 1.5 mmol/mg protein/mg tissue vs MTZL: 28.1 ± 2.3 mmol/mg protein/mg tissue vs VEH: 13.1 ± 0.5 mmol/mg protein/mg tissue; P = 0.018 for MTZDF vs VEH and P < 0.01 for MTZL vs VEH). Infarct size was significantly decreased in the MT groups (MTZDF: 11.8 ± 0.7% vs MTZL: 9.9 ± 0.5% vs VEH: 52.0 ± 1.4%; P < 0.01 each).

Mitochondrial transplantation significantly enhances post-ischaemic myocardial functional recovery and significantly decreases myocellular injury in the diabetic heart.

Prognostic assessment of valvular surgery in active infective endocarditis: multicentric nationwide validation of a new score developed from a meta-analysis.

European Journal of Heart Failure

Several risk prediction models have been developed to estimate the risk of mortality after valve surgery for active infective endocarditis (IE), but few external validations have been conducted to assess their accuracy. We previously developed a systematic review and meta-analysis of the impact of IE-specific factors for the in-hospital mortality rate after IE valve surgery, whose obtained pooled estimations were the basis for the development of a new score (APORTEI). The aim of the present study was to assess its prognostic accuracy in a nationwide cohort.

We analysed the prognostic utility of the APORTEI score using patient-level data from a multicentric national cohort. Patients who underwent surgery for active IE between 2008 and 2018 were included. Discrimination was evaluated using the area under the receiver operating characteristic curve, and the calibration was assessed using the calibration slope and the Hosmer-Lemeshow test. Agreement between the APORTEI and the EuroSCORE I was also analysed by Lin's concordance correlation coefficient (CCC), the Bland-Altman agreement analysis and a scatterplot graph.

The 11 variables that comprised the APORTEI score were analysed in the sample. The APORTEI score was calculated in 1338 patients. The overall observed surgical mortality rate was 25.56%. The score demonstrated adequate discrimination (area under the receiver operating characteristic curve = 0.75; 95% confidence interval 0.72-0.77) and calibration (calibration slope = 1.03; Hosmer-Lemeshow test P = 0.389). We found a lack of agreement between the APORTEI and EuroSCORE I (concordance correlation coefficient = 0.55).

The APORTEI score, developed from a systematic review and meta-analysis, showed an adequate estimation of the risk of mortality after IE valve surgery in a nationwide cohort.

Sex-specific outcome after minimally invasive direct coronary artery bypass for single-vessel disease.

Interactive Cardiovascular and Thoracic Surgery

Female gender is reported as an independent risk factor for a poor outcome after coronary artery bypass grafting. We analysed the influence of gender on surgical outcome in patients with single-vessel disease undergoing minimally invasive direct coronary artery bypass (MIDCAB).

From January 1998 to December 2016, a total of 607 consecutive patients with single-vessel disease (31.9% women) underwent MIDCAB at our institution. Major adverse cardiac and cerebrovascular events (MACCE) were recorded during a median follow-up period of 8.0 years. Survival time was estimated for all patients and after applying propensity score matching (138 women vs 138 men). Multivariable Cox regression analysis identified risk factors predicting a long-term mortality rate.

In women, a longer surgical time (125 vs 113 min; P < 0.001) and a higher transfusion rate were recorded (13.0% vs 5.1%; P = 0.001) with similar rates of in-hospital deaths (1.0% vs 0.5%; P = 0.60) and MACCE (1.5% vs 0.7%; P = 0.39). Survival and MACCE-free survival during the follow-up period did not differ significantly between genders (P = 1.0, P = 0.36). Survival and MACCE-free survival rates after 5 years were 94% and 90% in women compared to 91% and 86% in men. Propensity score matching demonstrated improved long-term survival rates in women (P = 0.029). Insulin-dependent diabetes mellitus, postoperative atrial fibrillation and prolonged intensive care unit stay were associated with long-term deaths for both genders, whereas obesity, former myocardial infarction and preoperative atrial fibrillation were significant risk factors in men.

Female patients showed no adverse outcomes after MIDCAB, although risk factors were gender-specific. Overall, MIDCAB demonstrated excellent short- and long-term results as a treatment for single-vessel disease in both genders.

An in vitro comparison of internally versus externally mounted leaflets in surgical aortic bioprostheses.

Interactive Cardiovascular and Thoracic Surgery

To improve haemodynamic performance, design modifications of prosthetic valves have been proposed with each new generation of valves. These different designs also impact the amount of mechanical wear, because mechanical stresses are distributed differently. Because long-term evidence for new prosthetic valves is lacking, this in vitro study compared hydrodynamic performance and durability among 3 currently available bioprosthetic valves with internally (IMLV) or externally mounted leaflets (EMLV).

Prostheses of the internally mounted Medtronic Avalus and Carpentier-Edwards Perimount Magna Ease valves were compared to prostheses of the externally mounted Abbott Trifecta valve. For each labelled size (e.g. 19, 21 and 23) of the 3 types, 3 valves underwent accelerated wear testing for up to 600 million cycles, corresponding to ∼15 years of simulated wear. The valves underwent hydrodynamic testing and visual inspection.

EMLV had the largest effective orifice area and lowest pressure gradient for each labelled size at baseline and 600 million cycles; the effective orifice area and the pressure gradient were equivalent for the 2 types of IMLV. Five of 9 EMLVs had at least 1 hole or tear in the leaflet tissue around the stent posts, which resulted in severe regurgitation at 500 million cycles in 2 cases. All IMLVs were intact at 600 million cycles with minimal tissue wear.

EMLV showed superior hydrodynamic performance but inferior mechanical durability compared to IMLV after 600 million cycles of testing. The primary failures were because of significant mechanical abrasion in the commissural region, which may warrant close monitoring of EMLV during long-term follow-up.