Redefining “low risk”: Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era

ObjectivesGuidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival.MethodsFrom January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality.ResultsWith 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex–matched population.ConclusionsSTS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.     

The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation

ObjectiveThe use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation.MethodsThe AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement.ResultsThe expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively.ConclusionsAchieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.     

Anemia is associated with higher mortality and morbidity after thoracic endovascular aortic repair

BackgroundIt is uncertain whether preoperative anemia is independently associated with thoracic endovascular aortic repair (TEVAR) outcomes. Using a national vascular surgery database, we evaluated the associations between preoperative anemia and 30-day mortality, postoperative complications, and 1-year survival for patients undergoing TEVAR.MethodsWe retrospectively analyzed all patients in the Vascular Quality Initiative who had undergone TEVAR for aortic dissection, aortic aneurysm, penetrating aortic ulcer, hematoma, or thrombus between January 2011 and December 2019. We excluded patients with a ruptured aneurysm, traumatic dissection, emergent repair, treated aorta distal to zone 5, polycythemia, transfusion of >4 U of packed red blood cells intraoperatively or postoperatively, and missing data on hemoglobin level or surgical indications. The final study cohort was dichotomized into two groups: normal/mild anemia (women, ≥10 g/dL; men, ≥12 g/dL) and moderate/severe anemia (women, <10 g/dL; male, <12 g/dL). Propensity scores by stratification were used to control for confounding in the analysis of the association between the outcomes of 30-day mortality, postoperative complications, and 1-year survival and a binary indicator variable of moderate/severe anemia vs normal/mild anemia. Kaplan-Meier analysis and log-rank tests were used to compare the 1-year survival between the two groups. A Cox regression model was fitted to assess the associations between anemia and survival outcomes.ResultsA total of 3391 patients were analyzed, 958 (28.3%) of whom had had moderate/severe anemia. After adjustment for multiple clinical factors using propensity score stratification, moderate/severe anemia was associated with a 141% increased odds of 30-day mortality (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 1.15-5.05; P = .019), 58% increased odds of any in-hospital complication (aOR, 1.58; 95% CI, 1.17-2.13; P = .003), 281% increased odds of intraoperative transfusion (aOR, 3.81; 95% CI, 2.68-5.53; P < .001). In addition, moderate/severe anemia was associated with significantly worse survival within the first year after TEVAR (log-rank P < .001; 1-year survival rate using Kaplan-Meier estimates, 86.4% ± 1.3% standard error vs 92.5% ± 0.6% standard error) and with an increased risk of mortality in the first postoperative year (adjusted hazard ratio, 1.81; 95% CI, 1.16-2.82; P = .009).ConclusionsWe found that moderate or severe anemia is associated with significantly increased odds of mortality, postoperative complications, and worse 1-year survival after TEVAR. Future studies are needed to evaluate the effect of anemia correction on the outcomes of TEVAR.     

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting

BackgroundRecent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase.MethodsPatients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score–matched analyses were used to compare patients with and without mitral intervention.ResultsA total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; P_trend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; P_trend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5).ConclusionsConsistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.     

颈后路椎弓根钉棒短节段内固定治疗寰枢椎骨折脱位

目的:探讨颈后路椎弓根钉棒短节段内固定治疗寰枢椎骨折脱位的临床疗效。方法:对2015年1月至2018年1月手术治疗的60例寰枢椎骨折脱位患者进行回顾性分析,根据手术方法的不同分为研究组和对照组,其中研究组30例,男13例,女17例;年龄(39.32±2.85)岁;行颈后路椎弓根钉棒短节段内固定术。对照组30例,男12例,女18例;年龄(39.57±2.90)岁;行寰椎后路椎板夹内固定。记录两组患者手术时间、术中出血量、术后下床活动时间和住院时间以及并发症,观察两组患者疼痛视觉模拟评分(visual analogue scale,VAS),神经功能日本骨科协会(Japanese Orthopedic Association,JOA)评分及融合情况。结果:两组患者均获得至少12个月随访。研究组手术时间、术中出血量、术后下床活动时间及住院时间均优于对照组(P=0.000)。研究组发生呼吸道损伤1例;对照组发生切口感染2例,呼吸道损伤3例,相邻节段关节退变3例;研究组并发症发生率低于对照组(χ²=4.705,P=0.030)。术后1、3、7 d,研究组VAS低于对照组(P=0.000);术后1、3个月时,研究组JOA评分高于对照组(P=0.000)。术后12个月研究组患者均获得骨性融合;对照组出现3例骨性融合不佳,3例内固定断裂,发生率为20.00%(6/30);两组差异有统计学意义(χ²=4.629,P=0.031)。结论:颈后路椎弓根钉棒短节段内固定治疗寰枢椎骨折脱位具有创伤小、手术时间短、并发症少、疼痛程度轻等优势,且可促使神经功能尽快恢复。     

胸腰椎肿瘤椎体矢状切除的安全性和有效性

【摘要】 目的：评价椎体矢状切除技术在胸腰椎肿瘤中的安全性、有效性,探讨椎体分区、分型对手术的指导意义。方法：以椎体椎弓根的内侧缘、外侧缘和椎体中线为界,将椎体的解剖部位对称地分为Ⅰ/Ⅱ/Ⅲ区,并根据此分区进行分型,Ⅰ型,肿瘤累及Ⅰ区,矢状切除范围为同侧Ⅰ～Ⅱ区;Ⅱ型,肿瘤累及Ⅱ区,矢状切除同侧Ⅰ～Ⅲ区;Ⅲ型,肿瘤累及Ⅲ区,矢状切除同侧Ⅰ～Ⅲ区及对侧Ⅲ区。根据纳入排除标准,收集于2018年6月～2021年12月在我科进行胸腰椎肿瘤矢状切除的患者共8例,男性6例（75%）,女性2例（25%）,平均年龄37.8±4.8岁。骨肉瘤2例,软组织肉瘤2例,转移癌2例,良性局部侵袭性肿瘤2例。Ⅰ型1例,Ⅱ型2例,Ⅲ型5例。分别收集患者一般资料、手术相关临床数据,包括肿瘤累及分区、手术时间、术中失血量、重建方式、手术并发症、复发率、远期并发症、Frankel分级,随访观察该术式的治疗效果。结果：随访时间22.3±3.9个月（12～40个月）,术中失血量为1812.5±333.0ml,手术时间为369.6±27.7min。有1例软组织切缘阳性,因患者在外院首次手术造成硬膜粘连,我院进行第二次手术;所有患者骨切缘均为阴性。肿瘤学结果包括1例肿瘤局部复发合并远处转移,局部复发率12.5%（1/8）,1例远处转移,无感染及死亡病例,未见内固定失败病例。Frankel分级手术后未见恶化情况。结论：基于我们提出的分区、分型系统,可以有效指导胸腰椎肿瘤的椎体矢状切除,保留部分椎体,有助于减少手术并发症。     

区域麻醉在心脏手术快速康复中的应用进展

正中劈开胸骨的心脏手术创伤大,术后加速康复一直是手术和麻醉的重点和难点。目前,由于区域麻醉可以阻断疼痛的传导通路,减少手术应激,有益于术后镇痛,因此已广泛应用于普通外科手术的辅助麻醉。由于心脏手术中心肺转流需要全身肝素化,区域麻醉的应用一直存在争议。本文对几种常见的应用于正中劈开胸骨的心脏手术的区域麻醉方式及其并发症等研究状况进行综述,为开胸心脏手术麻醉管理提供参考。     

不同复位策略结合经皮椎体成形术治疗老年单节段胸腰椎骨质疏松性椎体压缩性骨折

目的 探讨不同复位策略结合经皮椎体成形术（PVP）治疗老年单节段胸腰椎骨质疏松性椎体压缩性骨折（OVCF）的临床疗效。方法 2019年3月—2021年3月,海军军医大学长征医院收治老年单节段胸腰椎OVCF患者84例,其中54例采取手法复位结合PVP治疗（手法复位组）,30例采用单纯PVP治疗（传统组）。记录术中骨水泥注入量及术后骨水泥渗漏情况;测量手术前后伤椎Cobb角及伤椎前缘高度,计算伤椎前缘高度恢复率;采用疼痛视觉模拟量表（VAS）评分评价疼痛程度。结果 所有手术顺利完成,患者随访> 12个月。手法复位组术中骨水泥注入量明显大于传统组,差异有统计学意义（P < 0.05）;但2组骨水泥渗漏率差异无统计学意义（P > 0.05）。2组术后伤椎Cobb角、伤椎前缘高度及VAS评分较术前显著改善,手法复位组改善情况优于传统组,差异均有统计学意义（P < 0.05）。结论 手法复位结合PVP治疗老年单节段胸腰椎OVCF临床效果良好,可更有效地恢复椎体高度,维持脊柱序列稳定性,改善患者临床症状。     

外固定器牵拉腰椎对马尾诱发电位及功能的影响

为研究马尾神经对牵拉损伤的耐受极限及其在不同强度损伤下的变化过程，作者设计了动物马尾神经牵拉损伤的模型。手术将家犬Ｌ_（３、４）椎骨间连接的韧带及椎间盘彻底松解，并在Ｌ_２、Ｌ_３、Ｌ_４及Ｌ_５椎体中各穿针一枚，连接外固定器。用外固定器撑大Ｌ_（３、４），椎骨间隙，于不同的牵拉强度和时间，检测动物马尾诱发电位、下肢疼痛反射和肌力。实验发现，急性２ｃｍ牵拉损伤可引起马尾诱发电位波形降低和畸变；立即去除牵拉损伤力，马尾诱发电位波形迅速恢复正常，次日动物肌力和疼痛反射恢复正常。但持久的２ｃｍ牵拉损伤，则造成持续的马尾诱发电位降低、畸变和运动、痛觉障碍。将牵拉损伤长度增加到３ｃｍ、４ｃｍ，则见到马尾诱发电位波形进一步降低、畸变，最后消失。由此可见椎骨间分离移位，可造成椎管内神经根牵拉损伤，使马尾诱发电位波幅降低或消失，并产生运动、痛觉障碍。轻度牵拉损伤引起的神经功能障碍是可以恢复的。但严重的牵拉损伤则引起不可逆转的神经功能障碍或丧失。