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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Epidemiology of acute kidney injury among paediatric patients after repair of anomalous origin of the left coronary artery from the pulmonary artery.

European Journal of Heart Failure

Acute kidney injury (AKI) is a prevalent complication after the surgical repair of paediatric cardiac defects and is associated with poor outcomes. Insufficient renal perfusion secondary to severe myocardial dysfunction in neonates is most likely an independent risk factor in patients undergoing repair for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). We retrospectively investigated the epidemiology and outcomes of children with ALCAPA who developed AKI after repair.

Eighty-nine children underwent left coronary reimplantation. The paediatric-modified risk, injury, failure, loss and end-stage (p-RIFLE) criteria were used to diagnose AKI.

The incidence of AKI was 67.4% (60/89) in our study. Among the patient cohort with AKI, 23 (38.3%) were diagnosed with acute kidney injury/failure (I/F) (20 with acute kidney injury and 3 with acute kidney failure). Poor cardiac function (left ventricular ejection fraction < 35%) prior to surgery was a significant contributing factor associated with the onset of AKI [odds ratio (OR) 5.55, 95% confidential interval (CI) 1.39-22.13; P = 0.015], while a longer duration from diagnosis to surgical repair (OR 0.97, 95% CI 0.95-1.00; P = 0.049) and a higher preoperative albumin level (OR 0.83, 95% CI 0.70-0.99; P = 0.041) were found to lower the risk of AKI. Neither the severity of preoperative mitral regurgitation nor mitral annuloplasty was associated with the onset of AKI. After reimplantation, there was 1 death in the no-AKI group and 2 deaths in the AKI/F group (P = 0.356); the remaining patients survived until hospital discharge. The median follow-up time was 46.5 months (34.0-63.25). During follow-up, patients in the AKI cohort were seen more often by specialists and reassessed more often by echocardiography.

Paediatric AKI after ALCAPA repair occurs at a relatively higher incidence than that suggested by previous reports and is linked to poor clinical outcomes. Preoperative cardiac dysfunction (left ventricular ejection fraction < 35%) is strongly associated with AKI. The beneficial effect of delaying surgery seen in some of our cases warrants further investigation, as it is not concordant with standard teaching regarding the timing of surgery for ALCAPA.

A clampless anastomosis technique using the aortic cannula mounted by a prosthetic graft for a severely calcified aorta in a patient with subclavian steal syndrome.

European Journal of Heart Failure

Patients with severely calcified aorta are at high risk of embolic stroke during surgery and it is not feasible to clamp the aorta, necessitating a...

Standardized subannular repair for type IIIb functional mitral regurgitation in a minimally invasive mitral valve surgery setting.

European Journal of Heart Failure

Subannular repair techniques in addition to undersized ring annuloplasty have been developed to address high mitral regurgitation (MR) recurrence rates after mitral valve repair in type IIIb MR. We compared the results of annuloplasty with simultaneous standardized subannular repair versus isolated annuloplasty, focusing on the periprocedural outcomes of minimally invasive procedures.

A consecutive series of 108 patients with type IIIb functional MR with severe signs of bileaflet tethering underwent an annuloplasty + subannular repair (group A; n = 60) versus isolated annuloplasty (group B; n = 48). The primary end point of this prospective, parallel cohort study was death or recurrent MR >2, 1 year postoperatively. The secondary end points were survival and clinical outcomes, with special regard for the minimally invasively treated subgroups.

Duration of surgery, cardiopulmonary bypass time and aortic cross-clamp time were comparable between both study groups. Procedural outcomes as well as echocardiographic outcome parameters were similar and independent of access (fully endoscopic versus full sternotomy). At the 12-month follow-up, death or MR >2 occurred in 3.3% (2/60) of patients in group A vs in 20.8% (10/48) of patients in group B (P = 0.037). The overall mortality rate during the follow-up period was 1.7% (1/60) in group A vs 12.5% (6/48) in group B (P = 0.041).

Standardized realignment of papillary muscles is feasible and reproducible via a minimally invasive approach, resulting in excellent periprocedural outcomes, and has a clear potential to significantly decrease MR recurrence and improve 1-year outcomes compared to isolated annuloplasty.

Total artificial heart implantation after right ventricular intimal spindle cell sarcoma.

European Journal of Heart Failure

This paper describes the case of a patient with a high-grade spindle sarcoma in the right ventricle. The patient underwent total cardiectomy follow...

Comparative study of the frozen elephant trunk and classical elephant trunk techniques to supplement total arch replacement for acute type A aortic dissection†.

European Journal of Heart Failure

In patients with acute type A aortic dissection, the use of the frozen elephant trunk (FET) procedure with total arch replacement (TAR) has been indicated for emergency operations to obtain thrombosis of the distal false lumen (FL). However, data comparing the FET and the classical elephant trunk (CET) procedures, including the incidences of mortality, morbidity, spinal cord injury and aortic remodelling, have not yet been reported. The goal of this study was to compare the early outcomes of TAR with the FET and the CET procedures.

The past 7 years of medical records of 323 patients with type A aortic dissection who underwent emergency surgery were reviewed retrospectively, and 148 patients who underwent TAR were shortlisted for the study. First, the patients were divided into 2 groups, the CET group (n = 115; age 65 ± 12 years) and FET group (n = 33; 67 ± 11 years), to compare the early operative outcomes, including mortality and morbidity. Second, 86 patients (CET 56; FET 30) fulfilling the inclusive criteria (inserted length of elephant trunk ≥5 cm, involvement of dissection at the descending aorta and sufficient computed tomographic evaluation at ≥6 months after the operation) were compared to evaluate the patency and diameter of the FL at each segment of the downstream aorta.

The in-hospital mortality rate was 8.1% (12/148), without significant differences between the 2 groups (CET 8.7% vs FET 6.1%; P = 1). No spinal cord ischaemia was encountered in either group. The incidence of postoperative FL patency at the level of the left lower pulmonary vein was 30% in the FET group, which was significantly lower than that in the preoperative state (73%) and in the CET group (77%). The downsizing of the aortic diameter at the distal edge of the CET or the FET, the left lower pulmonary vein and the coeliac axis was significant in the FET group 6 months after TAR.

According to our initial experience, the FET compared to the CET procedure showed comparable early complications and an advantage concerning FL thrombosis and aortic remodelling at early follow-up examinations.

Antegrade selective cerebral perfusion reduced in-hospital mortality and permanent focal neurological deficit in patients with elective aortic arch surgery†.

European Journal of Heart Failure

We retrospectively evaluated the outcome after elective aortic arch surgery with circulatory arrest to determine the impact of different brain protection strategies on neurological outcome and early and late survival.

A total of 925 patients were included. The patients were assigned to 2 groups based on the type of cerebral protection strategy used during circulatory arrest [hypothermic circulatory arrest (HCA) n = 224; antegrade selective cerebral perfusion (ASCP) n = 701]. The propensity score matching (1:1; 210 vs 210 patients) approach was used to minimize selection bias and to obtain comparable groups.

The overall in-hospital mortality and permanent focal neurological deficit rates were 5.6% (n = 52) and 5.4% (n = 50) and were significantly lower in patients who received ASCP (4.4% and 3.4%, respectively) as compared to those who underwent HCA (9.4% and 11.6%, respectively) (P = 0.005 and P < 0.001). The propensity-matched analysis showed significantly lower rates of in-hospital mortality [3.8% vs 9.5% (HCA)] and permanent focal neurological deficit in ASCP group [2.9% vs 11.9% (HCA)]. Multivariable logistic regression analysis revealed left ventricular ejection fraction <30%, age >70 years, coronary artery disease, circulatory arrest time >40 min and mitral valve disease as independent predictors of in-hospital mortality. The use of ASCP was protective for early survival. Cox regression analysis revealed that long-term mortality was independently predicted by age, left ventricular ejection fraction <30%, total arch replacement, prior cardiac surgery, PVD, chronic obstructive pulmonary disease and previous stroke, whereas ASCP was protective for late survival.

Elective aortic arch surgery is associated with acceptable early and late outcomes. The ASCP is associated with a significant reduction in-hospital mortality and occurrence of permanent neurological deficits.

Paraspinous muscle gene expression profiling following simulated staged endovascular repair of thoracoabdominal aortic aneurysm: exploring potential therapeutic pathways†.

European Journal of Heart Failure

Thoracic endovascular techniques for aneurysm repair offer less invasive alternatives to open strategies. Both approaches, however, are associated with the risk for neurological complications. Despite adjuncts to maintain spinal cord perfusion, ischaemia and paraplegia continue to occur during thoracoabdominal aortic aneurysm (TAAA) repair. Staging of such extensive procedures has been proven to decrease the risk for spinal cord injury. Archived biopsy specimens may offer insight into the molecular signature of the reorganization and expansion of the spinal collateral network during staged endovascular interventions in the setting of TAAA.

Biological replicates of total RNA were isolated from existing paraspinous muscle samples from 22 Yorkshire pigs randomized to 1 of 3 simulated TAAA repair strategies as part of a previous study employing coil embolization of spinal segmental arteries within the thoracic and lumbar spine. Gene expression profiling was performed using the Affymetrix GeneChip Porcine array.

Microarray analysis identified 649 differentially expressed porcine genes (≥1.3-fold change, P ≤ 0.05) when comparing paralysed and non-paralysed subjects. Of these, 355 were available for further analysis. When mapped to the human genome, 169 Homo sapiens orthologues were identified. Integrated interpretation of gene expression profiles indicated the significant regulation of transcriptional regulators (such as nuclear factor кB), cytokine (including CXCL12) elements contributing to hypoxia signalling in the cardiovascular system (vascular endothelial growth factor and UBE2) and cytoskeletal elements (like dystrophin (DMD) and matrix metallopeptidase (MMP)).

This study demonstrates the ability of microarray-based platforms to detect the differential expression of genes in paraspinous muscle during staged TAAA repair. Pathway enrichment analysis detected subcellular actors accompanying the neuroprotective effects of staged endovascular coiling. These observations provide new insight into the potential prognostic and therapeutic value of gene expression profiling in monitoring and modulating the arteriolar remodelling in the collateral network.

Early silent graft failure in off-pump coronary artery bypass grafting: a computed tomography analysis†.

European Journal of Heart Failure

The purpose was to assess predictors of early silent graft failure prior to discharge by multislice computed tomography in patients after off-pump coronary artery bypass grafting.

From January 2017 until April 2018, 192 computed tomographic scans of consecutive asymptomatic patients were performed (seventh postoperative day ± 4 days) and analysed retrospectively. In total, 359 arterial and 278 venous anastomoses were evaluated. Two patient groups (overall patent anastomoses versus at least 1 occluded anastomosis) were compared. Cardiovascular risk factors, collateralization according to Rentrop, grade of native vessel stenosis and intraoperative flow measurements were analysed. Inferential statistics were performed with the Mann-Whitney U-test. Nominal and categorical variables were tested with the Fisher-Freeman-Halton exact test.

In 33 patients, at least 1 occluded anastomosis could be identified, predominantly in women (P = 0.04). The patency of the arterial anastomoses was 96.4% and 88.9% for the venous anastomoses. In 14 patients with occluded anastomoses, a successful interventional revascularization was performed before discharge. There were significant differences in lower bypass flow [P = 0.02, odds ratio 3.2, 95% confidence interval (CI) 1.7-6.0] and higher pulsatility index (P < 0.001, odds ratio 4.5, 95% CI 2.4-8.5) in the occluded group. A calculated cut-off value identified an increased probability for graft occlusion at a flow under 23 ml/min and a pulsatility index greater than 2.3.

Early silent graft failure occurred predominantly in venous grafts, with a tendency to female gender. A lower flow rate and a higher pulsatility index were significantly associated with graft occlusion, whereas collateralization and the degree of native vessel stenosis seem to play a tangential role. Fourteen patients had a successful percutaneous revascularization before discharge.

NCT03657199.

The Bayley-III scale may underestimate neurodevelopmental disability after cardiac surgery in infants†.

European Journal of Heart Failure

Neurodevelopmental disability is the most common complication among congenital heart surgery survivors. The Bayley scales are standardized instruments to assess neurodevelopment. The most recent edition (Bayley Scales of Infant and Toddler Development 3rd Edition, Bayley-III) yields better-than-expected scores in typically developing and high-risk infants than the second edition (Bayley Scales of Infant Development 2nd Edition, BSID-II). We compared BSID-II and Bayley-III scores in infants undergoing cardiac surgery.

We evaluated 2198 infants who underwent operations with cardiopulmonary bypass between 1996 and 2009 at 26 institutions. We used propensity score matching to limit confounding by indication in a subset of patients (n = 705).

Overall, unadjusted Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores (90.7 ± 17.2 vs 77.6 ± 18.8, P < 0.001), and unadjusted Bayley-III composite cognitive and language scores were higher than BSID-II Mental Development Index scores (92.0 ± 15.4 vs 88.2 ± 16.7, P < 0.001). In the propensity-matched analysis, Bayley-III motor scores were higher than BSID-II Psychomotor Development Index scores [absolute difference 14.1, 95% confidence interval (CI) 11.7-17.6; P < 0.001] and the Bayley-III classified fewer children as having severe [odds ratio (OR) 0.24; 95% CI 0.14-0.42] or mild-to-moderate impairment (OR 0.21; 95% CI 0.14-0.32). The composite of Bayley-III cognitive and language scores was higher than BSID-II Mental Development Index scores (absolute difference 4.0, 95% CI 1.4-6.7; P = 0.003), but there was no difference between Bayley editions in the proportion of children classified as having severe cognitive and language impairment.

The Bayley-III yielded higher scores than the BSID-II and classified fewer children as severely impaired. The systematic bias towards higher scores with the Bayley-III precludes valid comparisons between early and contemporary cardiac surgery cohorts.

Propensity-matched comparison of the long-term outcome of the Nunn and two-patch techniques for the repair of complete atrioventricular septal defects†.

European Journal of Heart Failure

To compare the long-term performance of the Nunn and 2-patch techniques for the repair of complete atrioventricular septal defects.

Between January 1995 and December 2015, a total of 188 patients (Nunn n = 41; 2-patch n = 147) were identified from hospital databases. Univariable Cox regression was performed to calculate the risk of reintervention in each group. Propensity score matching was used to balance the Nunn group and the 2-patch group.

Baseline characteristics including age at surgery, weight, trisomy 21, other cardiac anomalies, previous operations and preoperative atrioventricular valve regurgitation did not differ between the 2 groups. Overall, there was no difference in mortality between the 2 groups (P = 0.43). Duration of cardiopulmonary bypass (CPB) and myocardial ischaemia time were 29 min (P < 0.001) and 28 min (P < 0.001) longer, respectively, in the 2-patch group. Median follow-up was 10.8 years (2-21 years). Unadjusted Cox regression did not reveal a significant difference in the risk of reoperation for either group 9 years after initial surgery [hazard ratio (HR) (Nunn) 0.512, 95% confidence interval 0.176-1.49; Nunn 89%; 2-patch 82%]. This finding was reiterated from Cox regression performed on the propensity-matched sample (31 pairs). The probability of freedom from moderate or worse left atrioventricular valve regurgitation or left ventricular outflow obstruction was similar in the 2 groups.

The Nunn and 2-patch techniques are comparable in terms of the long-term mortality and probability of freedom from reoperation, moderate or severe left atrioventricular valve regurgitation and left ventricular outflow obstruction. However, the duration of CPB and myocardial ischaemia is longer in the 2-patch group.

Identification and Validation of a Biomarker Signature in Patients With Resectable Pancreatic Cancer via Genome-Wide Screening for Functional Genetic Variants.

JAMA Surgery

Surgery currently offers the only chance for a cure in pancreatic ductal adenocarcinoma (PDAC), but it carries a significant morbidity and mortality risk and results in varying oncologic outcomes. At present, to our knowledge, there are no tests available before surgical resection to identify tumors with an aggressive biological phenotype that could guide personalized treatment strategies.

Identification of noninvasive genetic biomarkers that could direct therapy in patients whose cases are amenable to pancreatic cancer resection.

This multicenter study combined a prospective European cohort of patients with PDAC who underwent pancreatic resection (from University Hospital of Zurich, Zurich, Switzerland; Cantonal Hospital of Winterthur, Winterthur, Switzerland; and University Clinic of Ulm, Ulm, Germany) with data from the Cancer Genome Atlas database in the United States, which includes prospectively registered patients with PDAC. A genome-wide screening for functional single-nucleotide polymorphisms (SNPs) that affect PDAC survival was conducted using the European cohort for identification and the Cancer Genome Atlas cohort for validation. We used Cox proportional hazards models to screen for high-frequency polymorphic variants that are associated with allelic differences in tumor-associated survival and either result in an altered protein structure and function or reside in known regulatory noncoding genomic regions. The false-discovery rate method was applied for multiple hypothesis-testing corrections. Data analysis occurred from November 2017 to May 2018.

Pancreatic resection.

Tumor-associated survival.

A total of 195 patients in the European cohort were included, as well as 136 patients in the Cancer Genome Atlas cohort (overall median [range] age, 66 [19-87] years; 156 [47.1%] were women, and 175 [52.9%] were men). Two SNPs in noncoding, functional regions of genes that regulate cancer progression, invasion, and metastasis were identified (CHI3L2 SNP rs684559 and CD44 SNP rs353630). These were associated with survival after PDAC resection; patients who carry the risk alleles at 1 of both SNP loci had a 2.63-fold increased risk for tumor-associated death compared with those with protective genotypes (hazard ratio for survival, 0.38 [95% CI, 0.27-0.53]; P = 1.0 × 10-8).

The identified polymorphisms may serve as a noninvasive biomarker signature of prospective survival after pancreatic resection that is readily available at the time of PDAC diagnosis. This signature can be used to identify a subset of high-risk patients with PDAC with very low survival probability who might be eligible for inclusion in clinical trials of new therapeutic strategies, including neoadjuvant chemotherapy protocols. In addition, the biological knowledge about these SNPs could help guide the development of individualized genomic strategies for PDAC therapies.

Management Options for Gastric Variceal Hemorrhage.

JAMA Surgery

Varices are one of the main clinical manifestations of cirrhosis and portal hypertension. Gastric varices are less common than esophageal varices but are often associated with poorer prognosis, mainly because of their higher propensity to bleed.

Currently, treatments used to control and manage gastric variceal bleeding include β-blockers, endoscopic injection sclerotherapy, endoscopic variceal ligation, endoscopic variceal obturation, shunt surgery, transjugular intrahepatic portosystemic shunts, balloon-occluded retrograde transvenous obliteration (BRTO), and modified BRTO. In the past few decades, Western (United States and Europe) interventional radiologists have preferred transjugular intrahepatic portosystemic shunts that aim to decompress the liver and reduce portal pressure. Conversely, Eastern radiologists (Japan and South Korea) have preferred BRTO that directly targets the gastric varices. Over the past 20 years, BRTO has evolved and procedure-related risks have decreased. Owing to its safety and efficiency in treating gastric varices, BRTO is now starting to gain popularity among Western interventional radiologists. In this review, we present a comprehensive literature review of current and emerging management options, including BRTO and modified BRTO, for the treatment of gastric varices in the setting of cirrhosis and portal hypertension.

Balloon-occluded retrograde transvenous obliteration has emerged as a safe and effective alternative treatment option for gastric variceal hemorrhage. A proper training, evidence-based consensus and guideline, thorough preprocedural and postprocedural evaluation, and a multidisciplinary team approach with BRTO and modified BRTO are strongly recommended to ensure best patient care.