Both transsternal and video-assisted thoracoscopic surgery (VATS) approaches are used for thymectomy in myasthenia gravis. We compared outcomes of simultaneous experiences in two institutions: one ...utilizing the transsternal approach exclusively, the other using VATS procedures for all patients. The Myasthenia Gravis Foundation of America guidelines were used to standardize reporting.
Between March 1992 and September 2006, 95 thymectomies were performed for myasthenia gravis; 48 by VATS and 47 by transsternal approach. Preoperative classification and postoperative disease status were compared between the groups.
Mean age was 39.8 +/- 14.9 (VATS) versus 34.4 +/- 13.2 years (transsternal) (p = 0.07); the proportion of females was 52% versus 67% (p = 0.15); and preoperative duration of myasthenia gravis was 27 +/- 44 versus 20 +/- 45 months (p = 0.43), respectively. Clinical follow up was 89.5% complete at a mean of 6.0 +/- 4.0 years and 4.3 +/- 2.9 years (p = 0.03). The operative time was 128 +/- 34 minutes (VATS) versus 119 +/- 27 minutes (transsternal) (p = 0.22). The need for postoperative ventilation was 4.2% versus 16.2% (p = 0.07) and mean length of stay was 1.9 +/- 2.6 versus 4.6 +/- 4.2 days (p < 0.001). Thymomas were found in 8.3% of VATS versus 13.3% of transsternal patients (p = 0.44). No myasthenia gravis related deaths occurred and 95.8% of the VATS and 97.9% of the transsternal patients were in either complete stable remission, pharmacologic remission, or minimal manifestations status. In the VATS group, 13 of 17 (76.5%) patients stopped prednisone usage after surgery versus 5 of 14 (35.7%) in the transsternal group (p = 0.022).
Thymectomy is an effective treatment in patients with myasthenia gravis with equivalent clinical outcomes obtained by either approach.
Objective Risk algorithms were used to identify a high-risk population for transcatheter aortic valve implantation instead of standard aortic valve replacement in patients with aortic stenosis. We ...evaluated the efficacy of these methods for predicting outcomes in high-risk patients undergoing aortic valve replacement. Methods Data were collected on 638 patients identified as having isolated aortic valve replacement between January 1, 1998 and December 31, 2006, using The Society of Thoracic Surgeons (STS) database. Long-term survival was determined from the Social Security Death Index or family contact. Operative risk was calculated using the STS Predicted Risk of Mortality, the EuroSCORE logistic and additive algorithms, and the Ambler Risk Score. Patients at or above the 90th percentile of risk (8.38% for STS, 33.47% for logistic, 12% for additive, 14.3% for Ambler) were identified as high risk. We then compared actual with predicted mortality and each algorithm’s ability to identify patients with the worst long-term survival. Results Operative mortality was 24 of 638 (3.76%). An additional 121 (19.0%) patients died during the follow-up study period (mean 4.2 ± 2.7 years). Overall mortality was 145 of 638 (22.7%). Expected versus observed mortality for the high-risk group by algorithm was 13.3% versus 18.8% for STS, 50.9% versus 15.6% for logistic, 14.0% versus 11.9% for additive, and 19.0% versus 13.4% by Ambler. Long-term mortality, per high-risk group, was 64.1% in the STS Predicted Risk of Mortality, 45.3% in the logistic, 45.2% in the additive, and 40.2% in Ambler Risk Score. Logistic regression showed that the STS algorithm was the most sensitive in defining the patients most at risk for long-term mortality. Conclusion The STS Predicted Risk of Mortality most accurately predicted perioperative and long-term mortality for the highest risk patients having aortic valve replacement.
Background Advances in technology such as epicardial bipolar radiofrequency pulmonary vein isolation, ganglionated plexi identification, and isolation and thoracoscopic left atrial appendage ...exclusion have enabled less invasive surgical options for management of atrial fibrillation. Methods We performed a prospective, nonrandomized study of consecutive patients with symptomatic paroxysmal atrial fibrillation undergoing a video-assisted, minimally invasive surgical ablation procedure. The procedure consisted of bilateral, epicardial pulmonary vein isolation with bipolar radiofrequency, partial autonomic denervation, and selective excision of the left atrial appendage. Minimum follow-up was 1 year with long-term monitoring (24-hour continuous, 14-day event or pacemaker interrogation). Results Between March 2005 and January 2008, 52 patients (35 male), mean age 60.3 years (range, 42–79 years) underwent the procedure. The left atrial appendage was isolated in 88.0% (44/50). Average hospital stay was 5.2 days (range 3–10 days). There were no operative deaths or major adverse cardiac events. On long-term monitoring, freedom from atrial fibrillation/flutter/tachycardia was 86.3% (44/51) and 80.8% (42/52) at 6 and 12 months, respectively. Antiarrhythmic drugs were stopped in 33 of 37 patients and warfarin in 30 of 37 of the patients in whom ablation was successful at 12 months. Freedom from symptoms attributed to atrial fibrillation/flutter/tachycardia was 78.0% (39/50) at 6 months and 63.8% (30/47) at 12 months. Conclusions Minimally invasive surgical ablation is effective in the management of paroxysmal atrial fibrillation as evidenced by freedom from atrial arrythmias by long-term monitoring at 12 months. Measuring success using clinical symptoms underestimated clinical success as compared with long-term monitoring.
A volume-outcome association has been shown for cardiovascular procedures such as coronary artery bypass grafting. The association of a volume-outcome relationship for aortic valve replacement ...procedures, however, has not been clearly defined. We evaluated the influence of surgeon volume on operative outcomes with isolated aortic valve replacement and aortic valve replacement with concomitant coronary artery bypass grafting.
One thousand six hundred thirty-five patients were identified as having either isolated aortic valve replacement or aortic valve replacement plus coronary artery bypass grafting between January 1, 2000, and December 31, 2009. Patients were divided into three equal terciles using their Society of Thoracic Surgery Predicted Risk of Mortality scores. Data were retrieved on 14 surgeons with complete data records in our Society of Thoracic Surgery database covering a minimum 5-year period (mean, 8.9 ± 1.5 years; median, 10 years).
Clinically significant increases are seen in operative mortality, permanent stroke, renal failure, prolonged ventilation, and hospital and intensive care unit lengths of stay in the high-risk compared with low-risk groups. The low-risk patient group has the smallest observed to expected ratio, less than 50%, whereas in the high-risk group the ratio is greater than 1. Odds ratios demonstrate that as surgeon volume increases, outcomes improve correspondingly (ie, odds ratio <1). In low-risk patients, five of ten major complications demonstrated improved outcomes with increased surgeon volume; in medium and high-risk groups eight of ten were improved.
Surgeon volumes have a significant influence on operative outcomes in high-risk patients undergoing aortic valve replacement or aortic valve replacement with coronary artery bypass grafting.
In the past decade, minimally invasive approaches have been developed for aortic valve surgery. We reviewed our data to determine if the use of the PORT ACCESS technique has improved hospital ...morbidity and mortality.
Data were collected on 90 patients who had a replacement of their aortic valve using PORT ACCESS procedures (PORT ACCESS aortic valve replacement PAVR). This group was then matched 1:4 to a control group having aortic valve replacement surgery using a standard sternotomy approach.
The two groups had no statistically significant differences in preoperative risk factors. The perioperative and 30-day outcomes from the matched AVR and PAVR groups showed no mortalities in the PAVR group and 3.1% in the AVR group. Mean length of stay was shorter for PAVR patients (7.2 +/- 5.0 days; median 6 days) compared with the mean stay in the sternotomy group (8.5 +/- 9.5 days; median 6 days), PAVR patients also had statistically significant shorter intensive care unit stays, and time on ventilator. The number of patients needing ventilator support postoperatively was significantly lower in the PORT ACCESS group. Cross-clamp and perfusion times were longer in the PAVR group. No other morbidity was significantly different between groups, except for postoperative tamponade (higher in PAVR group).
In this analysis of matched patients, the patients having aortic valve replacement using PORT ACCESS procedures, spent a shorter time in the intensive care unit and had less need for postoperative ventilator usage (both number of patients using a ventilator and the mean time of use) in comparison with patients undergoing conventional sternotomy.
Various factors may influence outcomes after lobectomy for lung cancer. Postgraduate subspecialty training in general thoracic surgery with a focus on minimally invasive surgery (MIS) and thoracic ...oncology was completed by an established cardiothoracic surgeon on the hospital staff in July 2007, and principles emphasized in that training were incorporated into practice through formation of a subspecialty program. We hypothesized that establishing a dedicated general thoracic surgeon-lead subspecialty program, with focus on MIS and thoracic oncology, would improve short-term and long-term outcomes.
Patients entered into the hospital cancer registry have survival status updated annually through correspondence with patients, physicians, and searches of the Social Security Death Index and obituaries. The registry was queried for all patients undergoing lobectomy for lung cancer, 2002 to 2013, and divided into two groups for comparison, before and after, based on operation date relative to January 2008. Patients (n = 279) who had lobectomy for lung cancer were identified in the registry. Data included surgical approach (percent of video-assisted thoracoscopy VATS), pathologic stage, number of lymph nodes and stations sampled, hospital length of stay (LOS), and survival. χ
statistics were used for proportions, t tests for continuous variables, and a nonparametric test for LOS. A Cox proportional hazard model was created, and survival curves were constructed using time between operation and death or last follow-up.
Patients having lobectomy in the after group had substantially more VATS procedures (53.9% versus 9.5%), decreased LOS (median 3.5 versus 7.0 days), greater mean total lymph nodes (9.0 versus 6.3), and nodal stations (4.2 versus 2.8) sampled per patient. Thirty-day, 90-day, and 1-year survival were similar in both groups. Overall survival was better in the after group (hazard ratio HR 0.41, 95% confidence interval: 0.25 to 0.68), and this survival benefit remained statistically significant when comparing groups stratified by lung cancer stage (stage I: HR 0.46, stage II: HR 0.32, combined stage III to IV: HR 0.19).
Establishing a dedicated general thoracic surgeon-lead subspecialty program, with focus on MIS and thoracic oncology, can substantially improve short-term outcomes with increased VATS utilization, decreased LOS, and increased lymph node sampling. Long-term survival was also significantly improved.
Abstract Immediate surgery is standard therapy for acute type A aortic dissections (TAAD). Due to its low incidence, many smaller cardiac surgery programs do not routinely perform this procedure, ...because it may negatively impact outcomes. Many high risk, low volume surgical procedures are now preferentially performed in reference centers. We compared the outcomes of surgery for TAAD in high volume (HV) and low volume (LV) centers in a single metropolitan area to determine the optimal setting for treatment. Thirty five of the 37 cardiac surgery programs in the Dallas Ft. Worth metropolitan area participate in a regional consortium to measure outcomes collected in the Society of Thoracic Surgeons (STS) Adult Cardiac Database. Between 01/01/2008-12/31/2014, 29 programs had treated TAAD. Those programs performing at least 100 operations for TAAD were considered HV centers and the others LV. Surgery for TAAD was performed in 672 patients over the 7-year study period with HV centers performing 469/672 (70%) of the operations. Despite similar preoperative characteristics, operative mortality was significantly lower in HV versus LV centers (14.1% vs. 24.1%; p=0.001). There was no significant difference in postoperative paralysis rates (2.6% vs. 4.5%; p=0.196), stroke rates (10.7% vs. 9.4%; p=0.623) or 30-day readmission rates (12.1% vs.15.5%; p=0.292). An improved survival rate in HV centers was maintained over a 5-year follow-up period. Surgery for TAAD in a single large metropolitan area was most commonly performed in HV centers. In conclusion, the treatment of acute thoracic aortic dissection is recommended to be performed in reference centers because of lower early and midterm mortality.
Obesity is a worldwide healthcare concern, and its association with several chronic diseases is well documented. However, the effect obesity may have on the acute care delivery is not well ...understood, and in cardiac surgery, reports are conflicting. The purpose of this study is to evaluate the effect of obesity in an isolated aortic valve replacement population. The hypothesis is that increasing body mass index (BMI) will portend worse long-term outcomes and greater short-term resource utilization secondary to perioperative complications but will not affect perioperative mortality.
Data were collected on 1,066 patients undergoing isolated AVR between January 2000 and December 2010. All definitions follow The Society of Thoracic Surgeons guidelines. Body mass indexes were calculated and used both as a continuous independent variable and to categorize patients into three BMI groups. Long-term mortality follow-up was by Social Security Death Index search. Standard bivariate and multivariate comparisons were performed with hierarchical models used for odds ratios.
When controlling for standard covariates that negatively impact outcome (sex, age, renal failure needing dialysis, diabetes mellitus, and current smoker), BMI was not predictive for either operative mortality or a composite morbidity-mortality outcome. When divided into three equal-sized groups, there was again no statistical difference among groups for mortality or for the composite variable. Separate analyses for females and males yielded the same lack of correlation. Long-term follow-up out to 12 years shows that the low BMI group has statistically worse survival than the moderate or high BMI groups.
Increasing BMI has no independent association with worsened outcomes in the short or long term, and overweight patients have a survival benefit after surgery. Patients who are at the lower end of the BMI scale, however, are at increased risk for poor long-term survival.
Background A minimally invasive surgery for treatment of atrial fibrillation was developed with bilateral pulmonary vein isolation, mapping, and ablation of the ganglionic plexi and excision of the ...left atrial appendage. A prospective multicenter registry was created to evaluate the outcomes. Methods The procedure was performed through bilateral minithoracotomies with video assistance. It included bilateral pulmonary vein isolation with bipolar radiofrequency with documentation of conduction block, location of ganglionic plexi by high-frequency stimulation, and appropriate ablation and left atrial appendage exclusion/excision. Clinical follow-up at 6 months included monitoring with electrocardiogram, Holter, event monitor, or pacemaker interrogation. Results One hundred fourteen patients with 60 (52.6%) paroxysmal, 32 (28.1%) persistent, and 22 (19.3%) long-standing persistent atrial fibrillations were treated. The mean age was 59.5 ± 10.6 years, and 69.3% were men. The mean follow-up period was 204 ± 41 days (median 195). There were 2 (1.8%) operative mortalities. At 6-month follow-up, with long-term monitoring, 52/60 (86.7%) patients with paroxysmal fibrillations were in normal sinus rhythm and 43/60 (71.7%) were both in normal sinus rhythm and off antiarrhythmic drugs. The patients with persistent atrial fibrillation had a lower success rate, with 18/32 (56.3%) being in normal sinus rhythm and 46.9% both in normal sinus rhythm and off antiarrhythmic drugs; for long-standing persistent cases, 11/22 (50%) were in normal sinus rhythm and 7/22 (31.9%) were also off antiarrhythmic drugs. Conclusions Minimally invasive atrial fibrillation surgery is an effective treatment of paroxysmal atrial fibrillation at 6 months. Continuous event monitoring is necessary to accurately assess treatment results. A more extensive lesion set seems to be required for treatment of persistent atrial fibrillation.
Aortic valve replacement (AVR) is the treatment of choice for critical aortic stenosis. Selected patients have not previously been referred for AVR because of excessive risk of mortality and ...morbidity with surgery. The option of transcatheter aortic valve implantation (TAVI) has increased referral of this high-risk cohort for therapeutic intervention. We report the management and outcomes of these patients.
Patients referred for TAVI from December 2005 to December 2007 were evaluated and followed up for intermediate-term all cause mortality. Patients received medical management, TAVI, conventional AVR, or balloon valvuloplasty (BAV) based on risk profile, hemodynamic and echocardiographic criteria, physician judgment, or patient choice. Patients were compared for demographics, Society of Thoracic Surgeons predicted risk of mortality score, and outcomes after AVR, TAVI, or BAV.
One hundred five patients were referred for TAVI during a 24-month period. Fifty-two patients (49.5%) received medical management, 16 (15.2%) conventional AVR, 21 (20.0%) received TAVI, and 16 (15.2%) received BAV. Patients were classified as medical management because of physician or patient choice, not meeting TAVI criteria, or underevaluation for a possible procedure. For all patients the average length of follow-up was 159 +/- 147 days. Patients receiving BAV had a Society of Thoracic Surgeons predicted risk of mortality score greater than those having medical management, AVR, or TAVI. Thirty-day mortality was 1 of 16 patients (6.3%) for AVR, 2 of 21 patients (9.5%) with TAVI, 2 of 16 patients (12.5%) for BAV, and 7 of 52 patients (13.5%) for the medical management cohort. Overall mortality during follow-up was 42.3% (22 of 52 patients) for medical management, 19.1% (4 of 21 patients) for TAVI, 12.5% (2 of 16 patients) for AVR, and 37.5% (6 of 16 patients) for BAV.
The population of patients screened for transcatheter therapy is complex and heterogeneous. Medical management alone demonstrates a high mortality rate, and BAV, although providing transient symptomatic relief, does not favorably impact survival. The majority of referred patients (65.7%), including those that declined intervention, were candidates for some form of valve replacement therapy, either TAVI or AVR. Transcatheter aortic valve implantation can be performed in appropriately selected patients with good early and immediate-term outcomes.
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