Video-Assisted Thoracic Surgery in Patients With Previous Sternotomy and Cardiac Surgery.

OBJECTIVE: Although video-assisted thoracic surgery (VATS) lobectomy has become a standard approach for early-stage 1 lung cancer, concerns exist regarding potential damage to the heart or bypass grafts when VATS is performed after cardiac surgery via median sternotomy. We could find only case reports regarding VATS lobectomy after sternotomy for cardiac surgery. Therefore, we reviewed our series of patients who underwent VATS anatomic resections after sternotomy for cardiac surgery. METHODS: Between 1996 and 2010, there were 87 patients who underwent 88 pulmonary resections after sternotomy for coronary artery bypass grafting (64), valve replacement or repair (12), coronary artery bypass graft and valve replacement (6), and transplant (5). There were 10 women (11.5%) and 77 men (88.5%) with a mean age of 76.2 years. Diagnoses included lung cancer (83), pulmonary metastases (4), and benign disease (1). RESULTS: Dense adhesions between the lung and the mediastinum sometimes occur after cardiac surgery. Compared with the total series of 2684 VATS lobectomies, operations after sternotomy are associated with greater mortality (12, 0.4% vs 5, 5.7%), myocardial infarction (13, 0.5% vs 2, 2.3%), transfusion (45, 1.7% vs 12, 13.6), conversion to thoracotomy (188, 7% vs 14, 15.9%). Injury occurred to the left main pulmonary artery (1, 1%) and internal mammary artery graft (1, 1%). There were no intraoperative deaths. CONCLUSIONS: Previous sternotomy for cardiac surgery does increase the risk for VATS lobectomy. Conversion to thoracotomy should be considered if dense adhesions are found. Techniques to reduce the risk for the heart are discussed

Sex‐Related Differences in Clinical Outcomes After Thoracic Endovascular Aortic Repair

Background Thoracic endovascular aortic repair (TEVAR) has been increasingly used for the treatment of descending thoracic aortic aneurysms and dissections. This study sought to evaluate the influence of sex on outcomes after TEVAR. Methods and Results This was an observational study from the Nationwide Readmissions Database analyzing all patients who underwent TEVAR from 2010 to 2018. Sampling weights were used to generate national estimates. International Classification of Diseases–Clinical Modification codes were used to identify patients with thoracic aortic aneurysms or dissections who underwent TEVAR. Patients were dichotomized according to sex, and 1:1 propensity score matching was applied. Mixed model regression for in‐hospital mortality and weighted logistic regression with bootstrapping for 30‐day readmissions were performed. A supplemental analysis was performed according to pathology (aneurysm or dissection). A weighted total of 27 118 patients were identified. Propensity‐matching yielded 5026 risk‐adjusted pairs. Men were more likely to undergo TEVAR for type B aortic dissection, whereas women were more likely to undergo TEVAR for aneurysm. In‐hospital mortality was roughly 5% and was equivalent in the matched groups. Men were more likely to have paraplegia, acute kidney injury, and arrhythmias, while women were more likely to require transfusions after TEVAR. There were no significant differences in myocardial infarction, heart failure, respiratory failure, spinal cord ischemia, mesenteric ischemia, stroke, or 30‐day readmission between the matched groups. On regression analysis, sex was not an independent risk factor for in‐hospital mortality. Female sex was, however, significantly associated with a decreased odds of 30‐day readmission (odds ratio, 0.90 [95% CI, 0.87–0.92]; P<0.001). Conclusions Women are more likely to undergo TEVAR for aneurysms, while men are more likely to undergo TEVAR for type B aortic dissection. In‐hospital mortality after TEVAR is comparable among men and women irrespective of indication. Female sex is independently associated with a reduced odds of 30‐day readmission after TEVAR

Association of Thoracic Aortic Aneurysm Versus Aortic Dissection on Outcomes After Thoracic Endovascular Aortic Repair

Background Because thoracic endovascular aortic repair (TEVAR) has become the standard of care for complicated type B aortic dissection (TBAD) and descending thoracic aortic (DTA) aneurysm, it is important to understand outcomes and use of TEVAR across thoracic aortic pathologies. Methods and Results This was an observational study of patients with TBAD or DTA undergoing TEVAR from 2010 to 2018, using the Nationwide Readmissions Database. In‐hospital mortality, postoperative complications, admission costs, and 30‐ and 90‐day readmissions were compared between the groups. Mixed model logistic regression was used to identify variables associated with mortality. An estimated total of 12 824 patients underwent TEVAR nationally, of which 6043 had an indication of TBAD and 6781 of DTA. Patients with aneurysms were more likely to be older, women, have cardiovascular disease, and have chronic pulmonary disease compared with patients with TBAD. Weighted in‐hospital mortality was higher for TBAD (8% [1054/12 711] versus 3% [433/14 407], P<0.001), compared with DTA, as were all postoperative complications. Patients with TBAD had a higher cost of care during their index admission (57.3 versus 38.8 × $1000, P<0.001), compared with DTA. The 30‐day and 90‐day weighted readmissions were more frequent for the TBAD group compared with DTA (20% [1867/12 711] and 30% [2924/12 711] versus 15% [1603/14 407] and 25% [2695/14 407], respectively, P<0.001). On multivariable adjustment, TBAD was independently associated with mortality (odds ratio, 2.06 [95% CI, 1.68–2.52]; P<0.001). Conclusions After TEVAR, patients who presented with TBAD had higher rates of postoperative complications, in‐hospital mortality, and cost compared with DTA. The incidence of early readmission was substantial for patients undergoing TEVAR, faring worse for those undergoing TEVAR for TBAD as compared with DTA

Long‐Term Outcomes of Patients Undergoing Aortic Root Replacement With Mechanical Versus Bioprosthetic Valves: Meta‐Analysis of Reconstructed Time‐to‐Event Data

Background An aspect not so clear in the scenario of aortic surgery is how patients fare after composite aortic valve graft replacement (CAVGR) depending on the type of valve (bioprosthetic versus mechanical). We performed a study to evaluate the long‐term outcomes of both strategies comparatively. Methods and Results Pooled meta‐analysis of Kaplan‐Meier–derived time‐to‐event data from studies with follow‐up for overall survival (all‐cause death), event‐free survival (composite end point of cardiac death, valve‐related complications, stroke, bleeding, embolic events, and/or endocarditis), and freedom from reintervention. Twenty‐three studies met our eligibility criteria, including 11 428 patients (3786 patients with mechanical valves and 7642 patients with bioprosthetic valve). The overall population was mostly composed of men (mean age, 45.5–75.6 years). In comparison with patients who underwent CAVGR with bioprosthetic valves, patients undergoing CAVGR with mechanical valves presented no statistically significant difference in the risk of all‐cause death in the first 30 days after the procedure (hazard ratio [HR], 1.24 [95% CI, 0.95–1.60]; P=0.109), but they had a significantly lower risk of all‐cause mortality after the 30‐day time point (HR, 0.89 [95% CI, 0.81–0.99]; P=0.039) and lower risk of reintervention (HR, 0.33 [95% CI, 0.24–0.45]; P<0.001). Despite its increased risk for the composite end point in the first 6 years of follow‐up (HR, 1.41 [95% CI, 1.09–1.82]; P=0.009), CAVGR with mechanical valves is associated with a lower risk for the composite end point after the 6‐year time point (HR, 0.46 [95% CI, 0.31–0.67]; P<0.001). Conclusions CAVGR with mechanical valves is associated with better long‐term outcomes in comparison with CAVGR with bioprosthetic valves

Lower-extremity malperfusion syndrome in patients undergoing proximal aortic surgery for acute type A aortic dissectionCentral MessagePerspective

Objective: Data regarding management of lower-extremity malperfusion in the setting of type A aortic dissection are limited. This study aimed to compare acute type A aortic dissection with lower-extremity malperfusion outcomes in patients undergoing lower-extremity revascularization with no revascularization. Methods: Consecutive patients undergoing acute type A aortic dissection surgery were identified from a prospectively maintained database. Perioperative variables were compared between patients with and without lower-extremity malperfusion. Factors associated with lower-extremity malperfusion, revascularization, and mortality were determined using univariable Cox regression and Firth's penalized likelihood modeling. Results: From January 2007 to December 2021, 601 patients underwent proximal aortic repair for acute type A aortic dissection at a quaternary care center. Of these, 85 of 601 patients (14%) presented with lower-extremity malperfusion and were more often male (P = .02), had concomitant moderate or greater aortic insufficiency (P = .05), had lower ejection fraction (P = .004), had preoperative dialysis dependence (P = .01), and had additional cerebral, visceral, and renal malperfusion syndromes (P < .001). Kaplan–Meier estimated survival fared worse with lower-extremity malperfusion compared with no lower-extremity malperfusion at 1, 5, and 10 years (84% vs 77%, 74% vs 71%, 65% vs 52%, respectively, P = .03). In the lower-extremity malperfusion group, 15 of 85 patients (18%) underwent lower-extremity revascularization without significant differences in postoperative morbidity and mortality compared with patients not undergoing revascularization. Need for peripheral revascularization was associated with peripheral vascular disease (hazard ratio, 3.7 [1.0-14.0], P = .05) and pulse deficit (hazard ratio, 5.6 [1.3-24.0], P = .02) at presentation. Conclusions: Patients presenting with type A aortic dissection and lower-extremity malperfusion have worse overall survival compared with those without lower-extremity malperfusion. However, not all patients with type A aortic dissection and lower-extremity malperfusion require revascularization