Abstract OBJECTIVES Uniportal video-assisted thoracoscopic surgery (UniVATS) is widely used as a minimally invasive thoracic operation. The goal of our study was to analyse the effect of long-term experience with the UniVATS lobectomy on the learning curve. METHODS The learning curves were quantitatively evaluated by the unadjusted cumulative sum, and they were segmented using joinpoint linear regression analysis. The variables were compared between subgroups using trend analysis, and linear regression analysis was applied to correlate clinical characteristics at different stages of the learning curve with the duration of the operation. RESULTS The learning curve for the UniVATS lobectomy can be divided into 3 phases of proficiency at ∼200–300 procedures, with a fourth phase as the number of procedures increases. The 1st–52nd, 52nd–156th, 156th–244th and 244th–538th procedures comprised the preliminary learning stage, preliminary proficiency stage, proficiency stage and advanced proficiency stage, respectively. Surgical outcomes and their variability between stages improved with increasing case numbers, with the most significant addition of an auxiliary operating port and conversions. In multivariable analysis, as stages progressed, influences other than surgical experience increased the operative time, with male and extensive pleural adhesions in the preliminary proficiency stage; male and incomplete pulmonary fissures in the proficiency stage; and male, extensive pleural adhesions and incomplete pulmonary fissures in the advanced proficiency stage. CONCLUSIONS As the number of procedures increases, there may be 4 different proficiency stages in the UniVATS lobectomy learning curve. The surgeon enters the fourth stage at approximately the 244th procedure. Moreover, at stage 4, the perioperative indicators tend to stabilize, and influences other than surgical experience become more significant.
In the originally published version of this manuscript, there were errors in the figure in the Abstract. The text in the “Key question” box should read “Are gelatine sealing sheets more effective than fibrin sealing sheets in preventing surgical adhesions?” instead of “How do outcomes of ONCAB, OPCAB, PC and HCR compare in the setting of multivessel coronary artery disease?”. The text in the “Key finding(s)” box should read “The gelatine sealing sheets are more effective in preventing surgical adhesions than the fibrin sealing sheets.” Instead of “Whereas PCI had favourable early outcomes, surgical approaches were associated with lower risk of MACCE beyond 1year.” The text in the “Take-home message” box should read
OBJECTIVES Robot-assisted coronary bypass surgery has been developed as a less invasive alternative for conventional CABG enhancing postoperative recovery, patient satisfaction and early discharge to home destination. Furthermore, it may provide a basis for hybrid coronary revascularisation. To determine the feasibility of this procedure, we compared robot-assisted with conventional off-pump CABG. METHODS All consecutive patients undergoing a robot-assisted LIMA to LAD procedure were compared to consecutive patients undergoing conventional off-pump CABG for single-vessel disease from October 2016 to July 2019. Primary outcome was discharge to home destination within five days after surgery. Secondary outcomes were total hospital stay, reoperations within 48 hours, transfusion, atrial fibrillation, 30-day mortality, and quality of life one month after surgery. A propensity-matched cohort was composed to correct for possible confounders. RESULTS One hundred seven robot-assisted CABG patients were compared to 194 conventional off-pump CABG. Primary outcome was reached in 51% of the robot-assisted group versus 19% of the conventional off-pump group (p < 0.01). Median postoperative hospital stay was five days in the robot-assisted group versus seven days in the conventional off-pump group (p < 0.01). Other secondary outcomes did not differ significantly between groups, and quality of life one month after surgery was equal. The results after propensity matching were similar. CONCLUSION Early discharge to home destination is more frequent in robot-assisted CABG than in conventional off-pump CABG patients, with no difference in health-related quality of life. Therefore, this approach may reduce healthcare resources and provide a solid basis for hybrid coronary revascularisation.
Abstract OBJECTIVES Patients with left ventricular assist devices may experience external obstruction of the outflow graft through a gelatinous substance within the bend relief (BR; a stiff tube graft guiding the outflow graft). Preventative strategies have been missing. Having faced this problem, we decided to fenestrate the BR to avoid outflow graft obstruction (OGO). METHODS Since December 2010, 167 patients underwent left ventricular assist device implantation using HeartMate II or 3. BR fenestration was introduced on July 2018 (108 patients before, 59 after the introduction of BR fenestration). Follow-up computed tomography scans were obtained from all patients and were screened for OGO by 3 independent investigators. Results were correlated with log file history, echocardiographic and clinical outcomes. RESULTS Demographic data were comparable between groups, with mostly male patients. Patients with BR fenestration were older [63 (standard deviation (SD):10.6) vs 58 (SD: 10.7) years] and had shorter support duration [494 (SD: 383) vs 951 (SD: 875) days]. OGO was observed in 5 patients and occurred only in patients without fenestration. Importantly, it occurred late on postoperative Days 412, 462, 1043, 1184 and 1506. Three patients are still asymptomatic. Surgical revision was required in the other 2 patients for pump thrombosis or continuous low flow. One of them died 36 days after revision due to right heart failure. CONCLUSIONS Our results suggest that fenestration of the BR may be a preventative strategy to avoid external OGO. OGO occurred late, which suggests a careful long-term follow-up.
Summary The long-term results in studies comparing octogenarian patients who received either isolated surgical aortic valve replacement (i-SAVR) or coronary artery bypass grafting (CABG) in addition to SAVR are still debated. We performed a reconstructed time-to-event data meta-analysis of studies comparing i-SAVR and CABG+SAVR to evaluate the impact of CABG and to analyse the time-varying effects on long-term outcome. We performed a systematic review of the literature from January 2000 through November 2021, including studies comparing i-SAVR and CABG+SAVR, which reported at least 3-year follow-up and that plotted Kaplan–Meier curves of overall survival. The primary endpoint was overall long-term survival; secondary endpoints were in-hospital/30-day mortality and postoperative outcomes. The pooled hazard ratio (HR) and odds ratio) with 95% confidence interval (CI) were calculated for primary and secondary endpoints, respectively. Random-effect model was used in all analyses. Sixteen retrospective studies were included (5382 patients, i-SAVR = 2568 and CABG+SAVR = 2814). I-SAVR showed a lower incidence of in-hospital mortality compared to CABG+SAVR (odds ratio = 0.73; 95% CI= 0.60–0.89; P = 0.002). Landmark analyses showed a significantly higher all-cause mortality within 1 year from surgery in CABG+SAVR (HR = 1.17; 95% CI = 1.01–1.36; P = 0.03); after 1 year, no significant difference was observed (HR = 0.95; 95% CI = 0.87–1.04; P = 0.35). Landmark analysis was confirmed by time-varying trend of HR. Late survival of octogenarians did not differ significantly between the 2 interventions. Interestingly, CABG added to SAVR was associated with both higher in-hospital and within 1-year mortality after surgery, whereas this difference was statistically non-significant at long-term follow-up.
Abstract OBJECTIVES The aim of this study was to perform a meta-analysis of studies reporting outcomes in patients with liver dysfunction addressed by the model of end-stage liver disease and Child–Turcotte–Pugh scores undergoing cardiac surgery. METHODS A systematic literature search was conducted to identify contemporary studies reporting short- and long-term outcomes in patients with liver dysfunction compared to patients with no or mild liver dysfunction undergoing cardiac surgery (stratified in high and low score group based on the study cut-offs). Primary outcome was perioperative mortality. Secondary outcomes were perioperative neurological events, prolonged ventilation, sepsis, bleeding and/or need for transfusion, acute kidney injury and long-term mortality. RESULTS A total of 33 studies with 48 891 patients were included. Compared with the low score group, being in the high score group was associated with significantly higher risk of perioperative mortality [odds ratio (OR) 3.72, 95% confidence interval (CI) 2.75–5.03, P < 0.001]. High score group was also associated with a significantly higher rate of perioperative neurological events (OR 1.49, 95% CI 1.30–1.71, P < 0.001), prolonged ventilation (OR 2.45, 95% CI 1.94–3.09, P < 0.001), sepsis (OR 3.88, 95% CI 2.07–7.26, P < 0.001), bleeding and/or need for transfusion (OR 1.95, 95% CI 1.43–2.64, P < 0.001), acute kidney injury (OR 3.84, 95% CI 2.12–6.98, P < 0.001) and long-term mortality (incidence risk ratio 1.29, 95% CI 1.14–1.46, P < 0.001) CONCLUSIONS The analysis suggests that liver dysfunction in patients undergoing cardiac surgery is independently associated with higher risk of short and long-term mortality and also with an increased occurrence of various perioperative adverse events.
Abstract OBJECTIVES Although segmentectomy is an acceptable alternative to lobectomy for peripheral small-sized non-small-cell lung cancer, the effectiveness of segmentectomy for inner lesions remains unknown. The aim of this study was to examine the feasibility of segmentectomy in comparison with lobectomy for inner lesions. METHODS We retrospectively analysed 570 patients with small (≤2 cm) cN0 non-small-cell lung cancer who underwent segmentectomy or lobectomy between January 2007 and March 2021. We focused on patients with lesions located in the inner two-thirds, which were determined using three-dimensional computed tomography (n = 227). After propensity score matching analysis based on sex, age, pulmonary function, serum carcinoembryonic antigen level, radiographic tumour findings and tumour location, we compared the surgical and oncological outcomes in patients who underwent segmentectomy (n = 66) and lobectomy (n = 66). RESULTS Postoperative mortality or morbidity did not differ significantly between the 2 groups. The 5-year recurrence-free and overall survival rates in the segmentectomy and lobectomy groups were 93.6% vs 84.1% and 95.8% vs 87.9%, respectively. The differences between 2 groups were not significant (P = 0.62 and P = 0.23, respectively). The 2 groups also showed no differences in loco-regional recurrence. Multivariable Cox regression analysis revealed that segmentectomy had a comparable impact on recurrence-free survival (hazard ratio, 0.61; 95% confidence interval, 0.17–2.03; P = 0.43). CONCLUSIONS Segmentectomy for inner-located small-sized non-small-cell lung tumours could be an acceptable treatment in comparison with lobectomy.
Atrioventricular groove disruption is a rare and potentially fatal complication of mitral valve replacement. It does not occur with mitral valve repair. Friable tissues, advanced age and posterior annular calcification are important predisposing factors. Most ruptures usually occur in the operating room, which gives the operating surgeon a better chance at salvaging the situation. Nevertheless, mortality remains high particularly if the rupture happened in the intensive care unit or later and it can be as high as 50–90%. In dealing with this complication surgically, there are 2 major approaches that have been described in the literature, the ‘external’ and the ‘intracardiac’ the external repair technique is usually conducted on cardiopulmonary bypass using direct suturing or felt-reinforced suturing or both of the ruptured atrioventricular groove. This can be supplemented with the application of bioglue (cryolife). Further atrial patching and coronary bypass grafting of the circumflex coronary artery may be required [1]. The intracardiac approach entails going back on pump and under cardioplegic arrest, explant the MV prosthesis and patch the posterior atrioventricular groove with fresh autologous pericardium or bovine pericardium then place the prosthetics valve again [2]. There are case reports of utilizing other additional technical tips. Raevsky et al. present a case report of a 23-year-old female with shone complex, who developed atrioventricular groove disruption after mitral valve replacement. To accomplish the repair and because of difficult exposure, they had to utilize ‘the commando procedure principles’, sacrificing the native ‘bicuspid’ aortic valve [3]. That was a commendable salvage for a deadly complication. The way the problem was handled is innovative and though very complicated, the outcome was good. However, in our opinion, this is not for the average cardiac surgeon and the principle remains to emphasize that such complication should not happen. We should teach young surgeons how to avoid such a complication. Simple preservation of the posterior leaflet or at least part of it prevents this complication. In Deniz et al.’s series of 513 mitral valve replacement patients, there were no cases of ventricular rupture with preservation of the posterior leaflet [4]. Being careful in detaching the mitral valve from the papillary muscles and paying attention to details is of utmost importance. This case report involves a young patient with probably ‘good’ tissue quality and preserved left ventricular function. No doubt this contributed to patient’s recovery. Imagine this patient was a 70–75 years old (most patients reported in the literature are in the older age range) who has some mitral valve annular calcification, left ventricular dysfunction and friable tissues and underwen this procedure that took 475 min (almost 8 h) of pump time and 310 min (5 h) of aortic cross-clamping was performed. What would be the chances of survival? Honestly, very minimal!
A 46-year-old male patient presented with cardiac decompensation due to a giant left ventricular aneurysm combined with a severely reduced left ventricular function after a silent myocardial infarction. Left ventricular unloading was performed with a microaxial pump as a bridge to surgery. Myocardial function in the basal segments was preserved and surgical ventricular reconstruction was performed successfully.
`OBJECTIVES: Aortic valve-sparing root reimplantation (AVSRR) is a complex procedure, which offers the benefit of preserving the native aortic valve. Cardiac redo surgery is complex and time-consuming, and it is not known if David procedure is safe or beneficial in this context. METHODS: Between 1993 and 2019, we performed a total of 544 elective AVSRR operations at our centre. Patients were assigned to either group A (n = 30, redo) or group B (n = 514, first-time sternotomy). RESULTS: Aortic cross-clamp time was higher in the redo group (173[62] vs 125[31], P < 0.001). Cardiopulmonary bypass time was higher in the redo group as well (250[78] vs 179[51], P < 0.001). There were significantly more concomitant total arch replacements in the redo group (43.3% vs 5.8%, P < 0.001) using the 'beating heart' technique (20.0% vs 1.9%, P < 0.001). In-hospital mortality was comparable in both groups (3.3% vs 1.8%, P = 0.44). The rates for perioperative complications in terms of permanent neurological deficit and rethoracotomy were comparable between the 2 groups, too. Follow-up was complete for 99.6% of all patients and comprised a total of 584 patient-years. The 1-, 5-, 10- and 15-year survival rates were 90%, 81%, 60% and 55%, in group A (redo) and 96%, 90%, 78% and 67% in group B (native, P = 0.16), respectively. The rates for freedom from valve-related reoperation at 1, 5, 10 and 15 years after initial surgery were 96%, 92%, 92% and 92% in group A (redo) and 97%, 92%, 87% and 84% in group B (native, P = 0.52), respectively. CONCLUSIONS: Despite significantly more concomitant total arch replacements in the redo group, early mortality was comparable in both groups. We conclude that AVSRR can be performed in redo cardiac surgery without compromising the early postoperative outcome. Careful patient assessment and selection are mandatory when evaluating patients with a history of previous cardiac surgery for David procedure.
OBJECTIVES:Subclinical leaflet thrombosis is a silent phenomenon commonly observed following transcatheter aortic valve implantation (TAVI). Leaflet thrombosis is associated with ischaemic complications and structural valve deterioration. Prior studies have shown that blood stasis in neo-sinus contributes to the initiation and growth of subclinical leaflet thrombosis. This study aimed to quantify temporal and spatial characteristics of the flow field from a fundamental perspective.METHODS:in vitro experimental analysis and fluid-solid interaction simulations were employed to characterize the flow field of a transcatheter aortic valve (TAV) with an intra-annular design in a pulse duplicator. Blood residence time (BRT) and flow-induced viscous shear stress were measured in the neo-sinus and on the surface of TAV leaflets.RESULTS:Temporal and spatial velocity variations were observed in neo-sinus, indicating that the flow is time-dependent and fully three-dimensional. The degree of blood stasis in the neo-sinus (bulk fluid) and on the surface of the TAV leaflets highly depends on the local flow characteristics. Regional flow variation in the neo-sinus resulted in substantial variations in BRT magnitude in the neo-sinus and on the surface of the TAV leaflet. Areas with a high degree of blood stasis were observed near the fixed boundary edge of the leaflets.CONCLUSIONS:The study indicated that leaflet motion is a primary driver of flow in neo-sinus. Considering the substantial variations in BRT magnitude in the neo-sinus (bulk fluid), blood stasis should be quantified locally on the surface of foreign (valve) materials to avoid errors in forecasting the risk of subclinical leaflet thrombosis in patients undergoing TAVI.
OBJECTIVES: This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC). METHODS: Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10. RESULTS: There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence. CONCLUSIONS: VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.
OBJECTIVES: The aim of this study is to assess prospectively the validity and feasibility of segmentectomy using preoperative simulation and intravenous indocyanine green (ICG) with near-infrared (NIR) light thoracoscope to ensure a sufficient surgical margin. METHODS: This study was a prospective, single-centre, phase II, feasibility study. From February to July 2021, 20 patients were enrolled in this study. All patients underwent preoperative three-dimensional computed tomography angiography and bronchography using simulation software. The dominant pulmonary artery of the targeted segment was selected to determine the dissection line and measure the surgical margin to the tumour. Intraoperatively, after the planned dissection of the pulmonary artery, ICG (0.3 mg/kg) was administered intravenously and observed with NIR, and dissection was performed along the line determined by preoperative simulation. Postoperatively, the pathological margin was compared with the simulation margin. RESULTS: All surgeries were performed via an uniport (3.5-4.0-cm skin incision). The regions of segmentectomy were S2, S3, S6, S9 + 10 and S10 of the right side and S1 + 2 + 3, S3, S3 + 4 + 5, S6 and S8 of the left side. The difference between the simulation margin and the pathological margin was not significant (simulation 30.5 +/- 10.1 vs pathological 31.0 +/- 11.0 mm, P = 0.801). The simulation margin was well correlated with the pathological margin (R-2 = 0.677). The proportion of cases successfully achieving the pathological margin of error of plus or minus 10 mm of the simulation margin was 90% (18 of 20 cases). CONCLUSIONS: The combination of preoperative three-dimensional computed tomography simulation and ICG-NIR was effective for securing a sufficient margin in segmentectomy.
