Abstract
OBJECTIVES
Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and ...early outcomes of the surgical management of post-infarction PMR from an international multicentre registry.
METHODS
Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality.
RESULTS
A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P = 0.036, cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P = 0.031).
CONCLUSIONS
Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome.
Clinical trial registration
clinicaltrials.gov: NCT03848429.
Papillary muscle rupture (PMR) is an infrequent but life-threatening mechanical complication (MC) of acute myocardial infarction (AMI) 1.
Abstract
OBJECTIVES:
Minimally invasive video-assisted thoracic surgery (VATS) was first introduced in the early 1990s. For decades, numerous non-randomized studies demonstrated advantages of VATS ...over thoracotomy with lower morbidity and shorter hospital stay, but only recently did a randomized trial document that VATS results in lower pain scores and better quality of life. Opposing arguments for VATS have always been increased costs and concerns about oncological adequacy. In this paper, we aim to investigate the cost-effectiveness of VATS.
METHODS:
The study was designed as a cost–utility analysis of the first 12 months following surgery and was performed together with a clinical randomized controlled trial of VATS versus thoracotomy for lobectomy of stage 1 lung cancer during a 6-year period (2008–2014). All health-related expenses were retrieved from a national database (Statistics Denmark) including hospital readmissions, outpatient clinic visits, prescription medication costs, consultations with general practitioners, specialists, physiotherapists, psychologists and chiropractors.
RESULTS:
One hundred and three VATS patients and 103 thoracotomy patients were randomized. Mean costs per patient operated by VATS were 103 108 Danish Kroner (Dkr) (€13 818) and 134 945 Dkr (€18 085) by thoracotomy, making the costs for VATS 31 837 Dkr (€4267) lower than thoracotomy (P < 0.001). The difference in quality-adjusted life years gained over 52 weeks of follow-up was 0.021 (P = 0.048, 95% confidence interval −0.04 to −0.00015) in favour of VATS. The median duration of the surgical procedure was shorter after thoracotomy (79 vs 100 min; P < 0.001). The mean length of hospitalization was shorter following VATS (4.8 vs 6.7 days; P = 0.027). The use of other resources was not significantly different between groups. The costs of resources were lower in the VATS group. This difference was primarily due to reduced costs of readmissions (VATS 29 247 Dkr vs thoracotomy 51 734 Dkr; P < 0.001) and costs of outpatient visits (VATS 51 412 Dkr vs thoracotomy 61 575 Dkr; P = 0.012).
CONCLUSIONS:
VATS is a cost-effective alternative to thoracotomy following lobectomy for stage 1 lung cancer. Economical outcomes as measured by quality-adjusted life years were significantly better and overall costs were lower for VATS.
Clinical Trial Registration Number:
NCT01278888.
Abstract
OBJECTIVES
Pulmonary sarcomatoid carcinoma (PSC) is a rare malignant neoplasm that accounts for a small percentage of non-small-cell lung carcinoma (NSCLC). At least 10% of PSCs has a ...spindle and/or giant cell component, which is often associated with a poor prognosis. We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for the clinicopathological characteristics and surgical outcomes of PSCs.
METHODS
The SEER database (1973–2013) was queried for PSC. A comparison between PSC and other NSCLC patients was performed. Cox regression for overall survival (OS) and logistic regression for node-positive predictors were performed. A propensity-matched (1:2) analysis (including age, gender, grade and stage) among surgically treated cases was done to compare OS in PSC versus other NSCLCs.
RESULTS
A total of 955 899 NSCLC patients were identified; of these, 4987 patients had been diagnosed with PSC (0.52%). Men represented 60.9% of cases, with a median age of 68 years. The median size of the tumour was 5 cm and 3.5 cm in PSCs and NSCLCs, respectively (P < 0.001). PSC patients had significantly less Stage I, more high-grade tumours, advanced T stage, N+ disease and M1 disease (P < 0.001). In the PSC cohort, the most significant predictor of N+ disease on multivariate analysis was advanced T stage (P < 0.001). Predictors of OS in Stages I/II PSC on multivariate analysis were advanced age P < 0.001, hazard ratio (HR) = 1.03, male gender (P = 0.024, HR = 1.25), carcinosarcoma (P = 0.002, HR = 1.76), grade (P = 0.033, HR = 1.81), T stage (P = 0.003, HR = 1.75), N status (P = 0.001, HR = 1.90) and surgical resection (P < 0.001, HR = 0.58). Among matched surgically resected cohorts, a poorer prognosis for OS was evident in PSCs in early stages (I/II) than in other NSCLCs (P = 0.009).
CONCLUSIONS
PSC patients present with more advanced stage and with worse survival outcomes than other NSCLC patients. While surgical resection conveys a survival advantage in PSC, this group represents a population at a high risk for relapse and should be evaluated for novel adjuvant therapies.
Thoracoscopic sympathicotomy may be an effective treatment for disabling facial blushing in selected patients. Short- and mid-term results are good but very long-term results are scarce in the ...medical literature and there is no knowledge which extent of sympathicotomy is better long-term for isolated facial blushing.
We previously randomized 100 patients between a rib-oriented R2 or R2-R3 sympathicotomy for isolated facial blushing, and reported local effects, side effects and quality of life after 12 months. In the present study, we sent identical questionnaires to all patients after a median of 16 years (interquartile range 15-17 years).
The response rate was 66%. Overall, 82% reported excellent or satisfactory results on facial blushing, with significant better local effect after R2 sympathicotomy compared with R2-R3 sympathicotomy. Patients who underwent R2 sympathicotomy were also significantly more satisfied with the operation. We found no significant difference between R2 and R2-R3 sympathicotomy in quality of life or rates of compensatory sweating (77%) and recurrence of blushing (41%) which was milder than preoperatively in most patients.
R2 sympathicotomy should be the preferred approach for isolated facial blushing because of better local effect and higher satisfaction rates. Although this was a very long-term follow-up of the only randomized trial of its kind the response rate was limited leaving a risk of undetected bias.
Our aim was to report an anatomic model of an autologous flap based on the internal thoracic blood supply: the pedicled thoraco-chondro-costal flap; and establish the feasibility of various types of ...extended tracheal replacement with this novel flap, according to a newly proposed topographic classification.
In a cadaveric model, a cervicotomy combined with median sternotomy was performed. The incision was extended laterally to expose the chest wall. The internal thoracic pedicle was freed from its origin down to the upper limit of the delineated flap to be elevated. The perichondria and adjacent periostea were incised longitudinally to remove cartilages and adjacent rib segments, preserving perichondria and periostea. A full-thickness quadrangular chest wall flap pedicled on internal thoracic vessels was then elevated and shaped into a neo conduit to replace the trachea with the pleura as an inner lining.
Various types of extended non-circumferential and full-circumferential tracheal replacements were achieved with this composite flap. No anastomosis tension was noticed despite the absence of release manoeuvres.
This model could represent a suitable autologous tracheal substitute, which is long, longitudinally flexible and eventually transversely rigid. No microsurgical vascular anastomoses are required. The technique is reproducible. The perichondria and periostea would regenerate vascularized neo-cartilaginous rings, potentially decreasing the need for long-term stenting. The inner pleural lining could potentially transform into ciliated epithelium as shown in previous preclinical studies.
Aortic valve regurgitation (AR) frequently complicates the clinical course after left ventricular assist device (LVAD) implantation. Transcatheter aortic valve implantation (TAVI) has emerged as an ...alternative to surgical aortic valve replacement (SAVR) in this cohort with a mostly high surgical risk profile. The unique challenges in LVAD patients, such as presence of non-calcified aortic valves and annular dilatation, raise concerns about device migration and paravalvular leakage (PVL) leading to missing device success. This study evaluates procedural outcomes and survival rates in LVAD patients who underwent TAVI, emphasizing strategies to enhance device success.
Between January 2017 and April 2023, 27 LVAD patients with clinically significant AR underwent elective or urgent TAVI at our centre. Primary end-points were procedural success rates, without the need for a second transcatheter heart valve (THV) and postprocedural AR/PVL. Secondary outcomes included survival rates and adverse events.
Among the cohort, 14.8% received AR-dedicated TAVI devices, with none requiring a second THV. There was no intraprocedural AR, and 1 patient (25%) had AR > 'trace' at discharge. Additionally, 25.9% underwent device landing zone (DLZ) pre-stenting with a standard TAVI device, all without needing a second THV. There was no intraprocedural AR, and none to trace AR at discharge. Among the 59.3% receiving standard TAVI devices, 37.5% required a second THV. In this subgroup, intraprocedural AR > 'trace' occurred in 12.5%, decreasing to 6.25% at discharge. In-hospital mortality was 3.7%, and median follow-up survival was 388 days (interquartile range 208-1167 days).
TAVI yields promising procedural outcomes and early survival rates in LVAD patients with AR. Tailored TAVI devices and pre-stenting techniques enhance procedural success. Continued research into these strategies is essential to optimize outcomes in this complex patient cohort.
Our goal was to evaluate gender representation among session leaders and abstract presenters at European cardio-thoracic surgical annual meetings.
We did a descriptive study of the gender ...distribution among session leaders and abstract presenters at 2 European cardio-thoracic international meetings from 2017 to 2022. Data from publicly available programmes were used to generate a list of session leaders and abstract presenters. The primary outcome was to evaluate the proportion of female sessions leaders at the annual meetings. Descriptive analyses were performed including the Cochran-Armitage trend test for linear trend of proportions.
A total of 1025 sessions of 11 annual meetings of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Thoracic Surgeons were examined. A total of 397 (13.2%) out of 3007 total session leaders and 955 (15.2%) out of 6251 abstract presenters were female. From 2017 to 2022, the proportions of both female session leaders and abstract presenters trended significantly 10.4% to 21.9% (P < 0.001) and 13.7% to 18.3% (P < 0.001), respectively. The EACTS female members and female meeting attendees significantly increased from 2017 to 2022 11.1% to 15.9% (P < 0.001) and 23.7% to 26.9% (P < 0.001), respectively. Most of the women attendees at the EACTS and the European Society of Thoracic Surgeons meetings who were session leaders and speakers came from Germany, Italy, the United Kingdom and the United States.
Women are under-represented compared to men in leadership and speaking roles at European cardio-thoracic surgical annual meetings. In the past few years, an encouraging positive trend over time for female leadership roles has been noted; as a result, the proportion of female society members is represented at the annual meetings. However, a substantial gender gap still exists in leading roles of meeting attendees.
To compare oncologic outcomes after segmentectomy with division of segmental bronchus, artery and vein (complete anatomic segmentectomy) versus segmentectomy with division of <3 segmental structures ...(incomplete anatomic segmentectomy).
We conducted a single-centre, retrospective analysis of patients undergoing segmentectomy from March 2005 to May 2020. Operative reports were audited to classify procedures as complete or incomplete anatomic segmentectomy. Patients who underwent neoadjuvant therapy or pulmonary resection beyond indicated segments were excluded. Survival was estimated with Kaplan-Meier models and compared using log-rank tests. Cox proportional hazards models were used to estimate hazard ratios (HRs) for death. Cumulative incidence functions for loco-regional recurrence were compared with Gray's test, with death considered a competing event. Cox and Fine-Gray models were used to estimate cause-specific and subdistribution HRs, respectively, for loco-regional recurrence.
Of 390 cases, 266 (68.2%) were complete and 124 were incomplete anatomic segmentectomy. Demographics, pulmonary function, tumour size, stage and perioperative outcomes did not significantly differ between groups. Surgical margins were negative in all but 1 case. Complete anatomic segmentectomy was associated with improved lymph node dissection (5 vs 2 median nodes sampled; P < 0.001). Multivariable analysis revealed reduced incidence of loco-regional recurrence (cause-specific HR = 0.42; 95% confidence interval 0.22-0.80; subdistribution HR = 0.43; 95% confidence interval 0.23-0.81), and non-significant improvement in overall survival (HR = 0.66; 95% confidence interval: 0.43-1.00) after complete versus incomplete anatomic segmentectomy.
This single-centre experience suggests complete anatomic segmentectomy provides superior loco-regional control and may improve survival relative to incomplete anatomic segmentectomy. We recommend surgeons perform complete anatomic segmentectomy and lymph node dissection whenever possible.
Ventilatory efficiency minute ventilation-to-carbon dioxide output slope (VE/VCO2 slope) can be measured at sub-maximal workload during cardiopulmonary exercise test. The aim of this study is to ...assess the association between VE/VCO2 slope and outcome after lung cancer resections.
Retrospective, single-centre analysis on all patients undergoing lung resection for cancer (April 2014-August 2022) and with a preoperative cardiopulmonary exercise test. VE/VCO2 slope >40 was chosen as high-risk threshold. Logistic regression analysis was used to test the association of VE/VCO2 slope and several patient- and surgery-related factors with 90-day mortality.
A total of 552 patients were included (374 lobectomies, 81 segmentectomies, 55 pneumonectomies and 42 wedge resections). Seventy-four percent were minimally invasive procedures. Cardiopulmonary morbidity was 32%, in-hospital/30-day mortality 6.9% and 90-day mortality 8.9%. A total of 137 patients (25%) had a slope of >40. These patients were older (72 vs 70 years, P = 0.012), had more frequently coronary artery disease (17% vs 10%, P = 0.028), lower carbon monoxide lung diffusion capacity (57% vs 68%, P < 0.001), lower body mass index (25.4 vs 27.0 kg/m2, P = 0.001) and lower peak VO2 (14.9 vs 17.0 ml/kg/min, P < 0.001) than those with a lower slope. The cardiopulmonary morbidity among patients with a slope of >40 was 40% vs 29% in those with lower slope (P = 0.019). Ninety-day mortality was 15% vs 6.7% (P = 0.002). The 90-day mortality of elderly patients with slope >40 was 21% vs 7.8% (P = 0.001). After adjusting for peak VO2 value, extent of operation and other patient-related variables in a logistic regression analysis, VE/VCO2 slope retained a significant association with 90-day mortality.
VE/VCO2 slope was strongly associated with morbidity and mortality following lung resection and should be included in the functional algorithm to assess fitness for surgery.
This study aimed to determine the predictive factors of lymph node metastases in clinical T0-T1c stage non-small-cell lung cancers, so as to help making surgical strategy.
From January 2016 to ...December 2017, patients with clinical T0-T1c stage non-small-cell lung cancers were retrospectively reviewed. We elucidated the lymph node metastatic incidence and distribution according to the primary tumour radiographic findings and maximal standard uptake values, and extracted the associated clinicopathological factors. Univariable and multivariable logistic regressions were used to identify independent predictive parameters for lymph node metastases. The performance of predictive model was evaluated using receiver operating characteristic analysis.
A total of 517 patients were included. Seventy-two patients had lymph node metastases. Among patients with pure ground-glass nodule and solid component size ≤10 mm, none had any lymph node metastasis. Multivariable logistic regression analysis demonstrated that age, carcinoembryonic antigen level, solid component size, consolidation-tumour ratio and tumour maximal standard uptake values were independent predictors of lymph nodal metastases. Receiver operating characteristic analyses indicated that the area under the curve of predictive model in evaluating lymph node metastases was 0.838 (95% CI 0.791-0.886).
Younger age, elevated carcinoembryonic antigen level, larger solid component size, higher consolidation-tumour ratio and tumour maximal standard uptake values were associated with lymph node involvement. Employing such a predictive model in the future may affect the surgical option of lymph node excision for patients in cT1 stage non-small-cell lung cancer.
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