Molecular Markers, Immune Therapy, and Non-Small Cell Lung Cancer-State-of-the-Art Review for Surgeons.

Background: Lung cancer is a leading cause of cancer deaths in the United States. An increasing understanding of relevant non-small cell lung cancer (NSCLC) biomarkers has led to the recent development of molecular-targeted therapies and immune checkpoint inhibitors that have revolutionized treatment for patients with advanced and metastatic disease. The purpose of this review is to provide surgeons with a state-of-the-art understanding of the current medical and surgical treatment trends and their implications in the future of management of NSCLC. Materials and Methods: A systematic search of PubMed was conducted to identify English language articles published between January 2010 and March 2024 focusing on molecular markers, tumor targeting, and immunotherapy in the diagnosis and treatment of NSCLC. Case series, observational studies, randomized trials, guidelines, narrative reviews, systematic reviews, and meta-analyses were included. Results: There is now increasing data to suggest that molecular-targeted therapies and immune therapies have a role in the neoadjuvant setting. Advances in intraoperative imaging allow surgeons to perform increasingly parenchymal-sparing lung resections without compromising tumor margins. Liquid biopsies can noninvasively detect targetable mutations in cancer cells and DNA from a blood draw, potentially allowing for earlier diagnosis, personalized therapy, and long-term monitoring for disease recurrence. Conclusions: The management of NSCLC has advanced dramatically in recent years fueled by a growing understanding of the cancer biology of NSCLC. Advances in medical therapies, surgical techniques, and diagnostic and surveillance modalities continue to evolve but have already impacted current treatment strategies for NSCLC, which are encompassed in this review.

Minimally Invasive with Maximal Yield: A Narrative Review of Current Practices in Mediastinal Lymph Node Staging in Non-Small Cell Lung Cancer.

Background: Lung cancer remains the leading cause of cancer deaths in the United States despite declining incidence and improved outcomes because of advancements in early detection and development of novel therapies. Accurate mediastinal lymph node staging is crucial for determining prognosis and guiding treatment decisions, particularly for non-small cell lung cancer (NSCLC). Materials and Methods: A systematic search of PubMed was conducted to identify English language articles published between January 2010 and January 2024 focusing on preoperative lymph node staging in adults with NSCLC. Case series, observational studies, randomized trials, guidelines, narrative reviews, systematic reviews, and meta-analyses were included. Results: Various imaging modalities, surgical and nonsurgical procedures for mediastinal lymph node staging were reviewed, including positron emission tomography with computed tomography, cervical mediastinoscopy, video-assisted cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy, endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA), transesophageal endoscopic ultrasound-guided fine needle aspiration (EUS-FNA), and computed tomography-guided percutaneous lymph node biopsy. EBUS-FNA emerged as the preferred initial staging procedure because of its high sensitivity and low complication rate. Combining it with other procedures or confirmatory testing may be helpful in determining appropriate treatment. Conclusions: Although cervical mediastinoscopy remains a valuable confirmatory procedure in select cases, its role as a first-line staging modality is diminishing with the widespread adoption of EBUS-FNA and EUS-FNA. The combination of EBUS-FNA and EUS-FNA allows access to nearly all mediastinal lymph node stations with high diagnostic accuracy. Future research may further refine the selection criteria for invasive mediastinal staging procedures, ultimately optimizing patient outcomes in the management of NSCLC.

Long-Term Mortality Risk According to Cardiorespiratory Fitness in Patients Undergoing Coronary Artery Bypass Graft Surgery.

The aim of this study was to evaluate the association between cardiorespiratory fitness (CRF) and long-term survival in United States (US) Veterans undergoing CABG. We identified 14,550 US Veterans who underwent CABG at least six months after completing a symptom-limited exercise treadmill test (ETT) with no evidence of cardiovascular disease. During a mean follow-up period of 10.0 ± 5.4 years, 6502 (43.0%) died. To assess the association between CRF and risk of mortality, we formed the following five fitness categories based on peak workload achieved (metabolic equivalents or METs) prior to CABG: Least-Fit (4.3 ± 1.0 METs (n = 4722)), Low-Fit (6.8 ± 0.9 METs (n = 3788)), Moderate-Fit (8.3 ± 1.1 METs (n = 2608)), Fit (10.2 ± 0.8 METs (n = 2613)), and High-Fit (13.0 ± 1.5 METs (n = 819)). Cox proportional hazard models were used to calculate risk across CRF categories. The models were adjusted for age, body mass index, race, cardiovascular disease, percutaneous coronary intervention prior to ETT, cardiovascular medications, and cardiovascular disease risk factors. P-values < 0.05 using two-sided tests were considered statistically significant. The association between cardiorespiratory fitness and mortality was inverse and graded. For every 1-MET increase in exercise capacity, the mortality risk was 11% lower (HR = 0.89; CI: 0.88-0.90; p < 0.001). When compared to the Least-Fit category (referent), mortality risk was 22% lower in Low-Fit individuals (HR = 0.78; CI: 0.73-0.82; p < 0.001), 31% lower in Moderate-Fit individuals (HR = 0.69; CI: 0.64-0.74; p < 0.001), 52% lower in Fit individuals (HR = 0.48; CI: 0.44-0.52; p < 0.001), and 66% lower in High-Fit individuals (HR = 0.34; CI: 0.29-0.40; p < 0.001). Cardiorespiratory fitness is inversely and independently associated with long-term mortality after CABG in Veterans referred for exercise testing.

Effects of Concomitant CABG on Outcomes in Veterans Who Require Surgery for Endocarditis.

BACKGROUND: Infective Endocarditis (IE) is a complicated disease frequently accompanied by coronary artery disease (CAD) though no clear guidelines exist for when concomitant revascularization should be undertaken once valve surgery is indicated. Data on this topic within the United States (US) Veteran population, who have unique healthcare needs when compared to the civilian population, is sparse. We investigated the impact of concomitant coronary artery bypass grafting (CABG) on morbidity and mortality in US Veterans requiring surgical management of IE. METHODS: We identified 489 patients who underwent surgical management of IE between January 1 2010 and December 31 2020 at any of 43 Veterans Affairs (VA) cardiac surgery centers in the US. Patients were stratified based on who underwent concomitant CABG at the time of operation. Primary outcomes included the occurrence of postoperative myocardial infarction (MI), stroke, or mortality. Continuous variables were compared using independent t-tests or Mann Whitney U tests, and categorical variables were compared using the Chi square test. Cox proportional-hazard models were used to calculate risk for primary outcomes based on group. RESULTS: 61 patients (12.5%) underwent concomitant CABG for CAD. After adjusting for significant covariates, patients who underwent CABG had a higher long-term risk of MI (adjusted hazard ratios (aHR) 2.37, 95% CI: 1.29-4.35, p = 0.005) and higher risk of MI at 30-days (aHR 2.34, 95% CI: 1.06-5.19, p = 0.035). Concomitant CABG was not associated with long-term stroke or death, 30-day stroke or death, or perioperative complications. On sub-analysis of patients with moderate to severe CAD, rates of MI were higher in the CABG group at 30 days (25.9 vs. 3.4%, p = 0.016) and 1 year (33.3 vs. 3.4%, p = 0.004), though not long-term. The mean number of grafts was 1.51 ± 0.76, with only one graft performed in 65.6% (40/61) of patients. CONCLUSIONS: Concomitant CABG at the time of operation for IE was associated with increased risk of MI at 30-day and long-term, though most CABGs involved a low number of grafts. It was not associated with 30-day stroke or death, long term stroke or death, or perioperative complications. The optimal treatment of CAD noted during preoperative evaluation for veterans undergoing surgery for IE remains unclear.

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy.

BACKGROUND: Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans. METHODS: A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded. RESULTS: In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69]; p = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11]; p = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66]; p = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%; p = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%; p < 0.001) and longer length of stay (12.0 vs. 6.8 days; p < 0.001). CONCLUSION: This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications.

Endovascular Repair of Zone 0 Ascending Aortic Pseudoaneurysm: A Case Report.

Although open surgery is standard of care for ascending aortic pathology, endovascular approaches can be viable options. We report the case of a 77-year-old man with a 5.7-cm ascending aorta penetrating ulcer. Given his age and clinical profile, the patient underwent Zone 0 thoracic endovascular aortic repair.

Microbiology of Infective Endocarditis in United States Veterans - Association Between Causative Organism and Short- and Long-Term Outcomes.

BACKGROUND: Previous studies have elucidated the relationship between causative organism and outcomes in infective endocarditis, however this relationship has not been studies in United States Veterans. The aim of this manuscript is to evaluate the association between causative organism and short-term and long-term outcomes in United States (US) Veterans with infective endocarditis (IE) requiring surgical management between 2010-2020. METHODS: We analyzed 489 patients with surgically treated IE from the Veterans Affairs (VA) Surgical Quality Improvement Program and the VA Informatics and Computing Infrastructure databases. Patients were divided into groups using causative organism identified from blood or intraoperative cultures - Staphylococcus, Streptococcus, Gram-negative rods, Enterococcus, Polymicrobial, and Unknown/Culture Negative. Other identified organisms were excluded from analysis. Cox proportional hazard models were used to calculate risk for stroke/transient ischemic attack (TIA), myocardial infarction (MI), and death based on group. The models were adjusted for covariates using backward elimination. Continuous variables were compared using ANOVA or Kruskal-Wallis H tests, and categorical variables were compared using Chi square tests. RESULTS: Mean follow-up was 4.0 ± 6.3 years. Gram negative rods (GNRs) were associated with greater risk of long-term mortality (adjusted hazard ratios (aHR) 2.15, 95% CI: 1.20-3.86, p = 0.01). Enterococcus was associated with long-term risk of MI (aHR 2.05, 95% CI: 1.07-3.94, p = 0.03). Resistant organisms, such as methicillin-resistant staphylococcus aureus, were associated with long-term risk of MI (aHR 2.51, 95% CI: 1.14-5.45, p = 0.02). Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation (48 hrs) (aHR 1.76, 95% CI: 1.05-2.97, p = 0.034), tracheostomy (aHR 5.64, 95% CI: 2.35-13.55, p < 0.001), and prolonged ICU stay (5 days) (aHR 1.39, 95% CI: 1.01-1.91, p = 0.043). CONCLUSIONS: In US Veterans, polymicrobial infections had notably worse perioperative outcomes but similar long-term outcomes in comparison to monomicrobial infections. GNR infections were associated with increased long-term mortality. Enterococcus and resistant organisms were associated with increased long-term risk of MI. Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation, tracheostomy, and prolonged ICU stay.

Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans.

BACKGROUND: Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG. METHODS: Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristic diagnostics identified optimal inflection points between continuous risk factors and odds of CVA. RESULTS: Twenty-eight thousand seven hundred fifty-seven patients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p < .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF >55% (p < .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p < .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use. CONCLUSION: The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication.

Assessment of Lung Cancer Risk Among Smokers for Whom Annual Screening Is Not Recommended.

Importance: The US Preventive Services Task Force does not recommend annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years who are former smokers with 20 or more pack-years of smoking who quit 15 or more years ago or current smokers with less than 20 pack-years of smoking. Objective: To determine the risk of lung cancer in older smokers for whom LDCT screening is not recommended. Design, Settings, and Participants: This cohort study used the Cardiovascular Health Study (CHS) data sets obtained from the National Heart, Lung and Blood Institute, which also sponsored the study. The CHS enrolled 5888 community-dwelling individuals aged 65 years and older in the US from June 1989 to June 1993 and collected extensive baseline data on smoking history. The current analysis was restricted to 4279 individuals free of cancer who had baseline data on pack-year smoking history and duration of smoking cessation. The current analysis was conducted from January 7, 2022, to May 25, 2022. Exposures: Current and prior tobacco use. Main Outcomes and Measures: Incident lung cancer during a median (IQR) of 13.3 (7.9-18.8) years of follow-up (range, 0 to 22.6) through December 31, 2011. A Fine-Gray subdistribution hazard model was used to estimate incidence of lung cancer in the presence of competing risk of death. Cox cause-specific hazard regression models were used to estimate hazard ratios (HRs) and 95% CIs for incident lung cancer. Results: There were 4279 CHS participants (mean [SD] age, 72.8 [5.6] years; 2450 [57.3%] women; 663 [15.5%] African American, 3585 [83.8%] White, and 31 [0.7%] of other race or ethnicity) included in the current analysis. Among the 861 nonheavy smokers (<20 pack-years), the median (IQR) pack-year smoking history was 7.6 (3.3-13.5) pack-years for the 615 former smokers with 15 or more years of smoking cessation, 10.0 (5.3-14.9) pack-years for the 146 former smokers with less than 15 years of smoking cessation, and 11.4 (7.3-14.4) pack-years for the 100 current smokers. Among the 1445 heavy smokers (20 or more pack-years), the median (IQR) pack-year smoking history was 34.8 (26.3-48.0) pack-years for the 516 former smokers with 15 or more years of smoking cessation, 48.0 (35.0-70.0) pack-years for the 497 former smokers with less than 15 years of smoking cessation, and 48.8 (31.6-57.0) pack-years for the 432 current smokers. Incident lung cancer occurred in 10 of 1973 never smokers (0.5%), 5 of 100 current smokers with less than 20 pack-years of smoking (5.0%), and 26 of 516 former smokers with 20 or more pack-years of smoking with 15 or more years of smoking cessation (5.0%). Compared with never smokers, cause-specific HRs for incident lung cancer in the 2 groups for whom LDCT is not recommended were 10.54 (95% CI, 3.60-30.83) for the current nonheavy smokers and 11.19 (95% CI, 5.40-23.21) for the former smokers with 15 or more years of smoking cessation; age, sex, and race-adjusted HRs were 10.06 (95% CI, 3.41-29.70) for the current nonheavy smokers and 10.22 (4.86-21.50) for the former smokers with 15 or more years of smoking cessation compared with never smokers. Conclusions and Relevance: The findings of this cohort study suggest that there is a high risk of lung cancer among smokers for whom LDCT screening is not recommended, suggesting that prediction models are needed to identify high-risk subsets of these smokers for screening.

Direct Comparison of Outcomes After Transcatheter Aortic Valve Replacement in Veterans and Non-Veterans Using the Transcatheter Valve Therapy Registry.

OBJECTIVES: This study aims to compare veterans and non-veterans undergoing transcatheter aortic valve replacement (TAVR) using data from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) registry. METHODS: Patients undergoing TAVR at George Washington University (GWU) and veterans treated at Washington DC Veterans Affairs Medical Center (VAMC) who underwent TAVR at GWU from 2014-2020 were included. All patients were reported in the TVT registry. Emergency and valve-in-valve TAVR were excluded. Cohorts were divided based on veteran status. Operators were the same for both groups. Outcomes were compared at 30 days and 1 year. The primary outcome was mortality and secondary outcomes were morbidity metrics. RESULTS: A total of 299 patients (91 veterans, 208 non-veterans) were included. Veterans had higher rates of hypertension (87.9% vs 77.9%; P=.04), diabetes (46.7% vs 28.9%; P<.01), and lung disease (2.4% vs 11.0%; P<.001). Outcomes were not significantly different between veterans and non-veterans, including 30-day mortality (0% vs 2.9%, respectively; P=.18), 1-year mortality (9.8% vs 10.7%, respectively; P=.61), stroke incidence (0% vs 2.5%, respectively; P=.73), median intensive care unit stay (24 hours in both groups), and overall hospital stay (2 days in both groups). CONCLUSIONS: The affiliation between a VAMC and an academic medical center allowed for direct comparison between veterans and non-veterans undergoing TAVR by the same operators using the TVT registry. Despite significantly higher rates of comorbidities, veterans had equivalent outcomes compared with non-veterans. This may be in part due to the comprehensive care that veterans receive in the VAMC and this institution's integrated heart center team.

Epidemiology of Coronary Artery Disease.

Although the mortality of coronary artery disease (CAD) has declined over recent decades, CAD remains the leading cause of death in the United States (US) and presents a significant economic burden. Epidemiologic studies have identified numerous risk factors for CAD. Some risk factors-including smoking, hypertension, dyslipidemia, and physical inactivity-are decreasing within the US population while Others, including advanced age, diabetes, and obesity are increasing. The most significant historic advances in CAD therapy were the development of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and lipid-lowering medications. Contemporary management of CAD includes primary and secondary prevention via medical management and revascularization when appropriate based on best available evidence. Despite the increasing prevalence of CAD nationwide, there has been a steady decline in the number of CABGs and PCIs performed in the US for the past decade. Patients with CABG are becoming older and with more comorbid conditions, although mortality associated with CABG has remained steady.

Epidemiology of Valvular Heart Disease.

Acquired diseases of the aortic and mitral valves are the most common cause of morbidity and mortality among Valvular heart diseases. Aortic stenosis (AS) is increasing in incidence in the United States (4,43 US), driven largely by an aging demographic. Aortic valve replacement is the only effective treatment of AS and has a dramatic mortality benefit. Mitral valve regurgitation (MR) is the most common form of valvular heart disease (VHD) in the US, whereby MR is most often the result of mitral valve prolapse; rheumatic heart disease (RHD) is a more common etiology of MR in underdeveloped countries. interventions for MR in the US are increasing.

Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System.

INTRODUCTION: Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. METHODS: This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. RESULTS: Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n = 859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR) = 0.57; P = 0.03), shorter length of stay (median 13 versus 14 d; P = 0.04) and longer operative times (6.5 versus 6.0 h; P < 0.001). CONCLUSIONS: VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume.

Uniportal Video-Assisted Thoracoscopic Lung Resection: A Single-Surgeon Experience and Comparison with Multiportal Technique in the Veteran Population.

Background: Uniportal video-assisted thoracoscopic surgery (VATS) has been shown to offer improved postoperative outcomes compared with multiportal technique. Shorter operative time has rarely been described. Our objective was to compare operative time and clinical outcomes between uniportal and multiportal VATS approaches for lung resection. Methods: This is a retrospective review of patients that underwent video-assisted thoracoscopic lung resection at United States Veterans Affairs centers between 2008 and 2018 using the Veteran Affairs Surgical Quality Improvement Program. Cases were assigned to uniportal (single surgeon) or multiportal cohorts. Multivariable analysis of clinical outcomes was performed, adjusting for preoperative confounding covariates. Temporal trend in operative time in uniportal cohort was analyzed in the context of cumulative operative volume using Spearman's rank correlation coefficient, rho (ρ). Results: In total, 8,212 cases were selected from 2008 to 2018 at Veterans Affairs centers: 176 (2.1%) uniportal and 8036 (97.9%) multiportal cases. Uniportal cohort was significantly associated with shorter operative time (1.7 hours versus 3.1 hours, P < .001), higher adjusted odds of surgical site infection (adjusted odds ratio = 2.76; P = .005), and longer length of stay (6 days versus 5 days; P = .04). Uniportal cohort operative time decreased over time (ρ = -0.474), with most significant change corresponding with increased cumulative operative volume from 25 to 44 cases. Conclusions: Uniportal technique offered shorter operative duration in veterans compared with multiportal approach, validating its technical advantages. Operative time decreased as cumulative operative volume increased, demonstrating a learning curve. Future studies should prospectively investigate any association between operative time and clinical outcomes after thoracoscopic lung resection.

The Right Ventricle in the Trans-Catheter Era: A Perspective for Planning Interventions.

Dysfunction of the right ventricle (RV) is common in patients with advanced left-sided valve disease and the significant impact of RV dysfunction on both short and long-term outcome is well established. However, considerations of RV function are largely absent in current management guidelines for valve disease and cardiac procedural risk models. As the indications and use of trans-catheter therapies rapidly expand for patients with acquired valvular disease, it is critical for clinicians to understand and consider RV function when making decisions for these patients. This review summarizes contemporary data on the assessment of RV function, the prognostic importance of baseline RV dysfunction on surgical and transcatheter procedures for acquired left-sided valvular disease, and the relative impact of these interventions on RV function. Baseline RV dysfunction is a powerful predictor of poor short- and long-term outcome after any therapeutic intervention for acquired left-sided cardiac valve disease. Surgical intervention for aortic or mitral valve disease is associated with a significant but transient decline in RV function, whereas trans-catheter procedures generally do not appear to have detrimental effects on either longitudinal or global RV function. Guidelines for therapy in patents with acquired left-sided valvular disease should account for RV dysfunction. Whereas surgical intervention in these patients leads to a predictable decline in RV function, trans-catheter therapies largely do not appear to have this effect. Further study is needed to determine the impact of these findings on current practice.

Clinical Outcomes and Technical Approach of Thymectomy in the Veterans Health Administration.

BACKGROUND: Thymectomy is traditionally performed through a transsternal incision, but less invasive modalities have emerged, including transcervical, thoracoscopic, and robotic approaches. Despite the advantages of video-assisted thoracoscopic surgery (VATS) over thoracotomy, most thymectomies are performed through sternotomy. This study compared the use and 30-day postoperative outcomes of transsternal, transcervical, and VATS thymectomy in the Veterans Health Administration. METHODS: This was a retrospective review of veterans who underwent thymectomy through the Veterans Affairs Surgical Quality Improvement Program. Their 30-day outcomes were compared among techniques, by adjusting for confounding covariates. Temporal trends were analyzed using the Spearman' rank correlation coefficient, rho(ρ). RESULTS: From 2008 to 2019, 594 thymectomies were performed: 376 (63.3%) transsternal, 113 (19.0%) VATS (including robotic approaches), and 105 (17.7%) transcervical cases. VATS use increased from 0% in 2008 to 61% of case volume in 2019. Relative to the transsternal technique, VATS thymectomy was associated with decreased odds of pulmonary complications (adjusted odds ratio, 0.06; P = .028) and shorter hospital stay (2.9 ± 0.4 days shorter; P < .001). No difference in outcomes was detected between VATS and transcervical thymectomy. The postoperative complication rate decreased from 17.7% in 2008 to 5.6% in 2019 (ρ = -0.101; P = .014). Length of stay decreased from median 4 days in 2008 to 3 days in 2019 (ρ = -0.093; P = .026). In thymic cancer, VATS 5-year overall survival was noninferior to the transsternal approach (71.3% vs 74.6%; P = .54). CONCLUSIONS: The transsternal approach comprised most thymectomy cases in veterans, whereas VATS thymectomy use increased over time and was associated with favorable outcomes. The 30-day outcomes after thymectomy improved over time, which may reflect a trend toward wider use of less invasive approaches. Future studies should examine long-term outcomes.

Video-Assisted Thoracoscopic Surgery Lung Resection in United States Veterans: Trends and Outcomes versus Thoracotomy.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) offers reduced morbidity compared with open thoracotomy (OT) for pulmonary surgery. The use of VATS over time has increased, but at a modest rate in civilian populations. This study examines temporal trends in VATS use and compares outcomes between VATS and OT in the Veterans Health Administration (VHA). METHODS: Patients who underwent pulmonary surgery (wedge or segmental resection, lobectomy, or pneumonectomy) at Veterans Affairs centers from 2008 to 2018 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Project database. The cohort was divided into OT and VATS and propensity score matched, taking into account the type of pulmonary resection, preoperative diagnosis, and comorbidities. Thirty-day postoperative outcomes were compared. The prevalence of VATS use and respective complications over time was also analyzed. RESULTS: A total of 16,895 patients were identified, with 5,748 per group after propensity matching. VATS had significantly lower rates of morbidity and a 2-day reduction in hospital stay. Whereas 76% of lung resections were performed open in 2008, nearly 70% of procedures were performed using VATS in 2018. While VATS was associated with an 8% lower rate of major complications compared with thoracotomy in 2008, patients undergoing VATS lung resection in 2018 had a 58% lower rate of complications (p < 0.001). CONCLUSIONS: VATS utilization at VHA centers has become the predominant technique used for pulmonary surgeries over time. OT patients had more complications and longer hospital stays compared with VATS. Over the study period, VATS patients had increasingly lower complication rates compared with open surgery.

Impact of Trainee Involvement on Video-Assisted Thoracoscopic Lobectomy for Cancer.

BACKGROUND: Previous literature in other surgical disciplines regarding the impact of resident and fellow involvement on operative time and outcomes has yielded mixed results. The impact of trainee involvement on minimally invasive thoracic surgery is unknown. This study compared risk-adjusted differences in operative time and outcomes of video-assisted thoracoscopic lobectomy for cancer between cases performed with and without residents and fellows involved. METHODS: All patients undergoing elective video-assisted thoracoscopic lobectomy for cancer between 2008 and 2018 were identified in the Veterans Affairs Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: cases with residents and fellows involved, and cases performed only by attending surgeons. Primary outcomes included operative time, postoperative hospital length of stay, and composite 30-day morbidity and mortality. Secondary outcomes included factors associated with high and low trainee operative autonomy. RESULTS: A total of 3678 patients met study inclusion criteria. In all, 1780 cases were performed with residents and fellows involved (median postgraduate year, 5; interquartile range, 4-7). Multivariate analysis showed that operative time was significantly shorter in resident- and fellow-involved cases compared with attending-only cases (mean [SD], 3.6 [1.4] versus 3.8 [1.6] hours; P < .001). There were no significant differences in composite 30-day morbidity and mortality (16.0% versus 17.1%; adjusted odds ratio = 0.93; 95% confidence interval, 0.77-1.11; P = .40) or length of stay. Substratification of trainees by postgraduate year resulted in similar findings. Cases performed in July through October and those in the Northeastern United States were associated with low autonomy. CONCLUSIONS: Current training paradigms in thoracic surgery are safe, and the involvement of motivated and skilled trainees with appropriate supervision may benefit operative duration.

Impact of Timing of Smoking Cessation on 30-Day Outcomes in Veterans Undergoing Lobectomy for Cancer.

The adverse effects of tobacco use on postoperative outcomes are well documented. While smoking cessation is associated with overall improvement in long-term survival for lung cancer patients, the effects of cessation shortly before lung surgery are unclear. This study compares 30-day outcomes after lobectomy between active smokers, recent quitters, and nonsmokers. Patients who underwent lobectomy for cancer at national Veterans Affairs medical centers from 2012 to 2018 were retrospectively identified in the Veterans Affairs Surgical Quality Improvement Program database. The sample was stratified into 3 groups: smokers within 2 weeks of surgery ("active smokers"), those who quit between 2 weeks and 3 months prior to surgery ("recent quitters"), and "nonsmokers." Propensity score matching was performed to compare groups. Of 5715 patients who met inclusion criteria, 2696 were nonsmokers, 774 were recent quitters, and 2245 were active smokers. After propensity matching, 572 patients comprised each group. Compared to recent quitters, active smokers had 48% higher odds of suffering a pulmonary complication (95% confidence interval [CI]: 1.03-2.14; P = 0.035) and 72% higher odds of suffering multiple complications (CI: 1.07-2.76; P = 0.026). Relative to nonsmokers, active smokers had 81% higher odds of pulmonary complications (CI: 1.34-2.65; P = 0.003). No differences were detected in outcomes comparing recent quitters to nonsmokers. Veterans undergoing lobectomy for cancer who quit 2 weeks before surgery had less pulmonary complications than active smokers. Recent quitters have similar outcomes to nonsmokers. Surgeons should therefore encourage patients to quit smoking, including just prior to lung surgery.

Patient motivations for non-adherence to lung cancer screening in a military population.

BACKGROUND: Lung cancer remains the leading cause of cancer deaths in the United States, and lung cancer screening has been shown to decrease this mortality. Adherence to lung cancer screening is paramount to realize the mortality benefit, and reported adherence rates vary widely. Few reports address non-adherence to screening, and our study sought to understand the non-compliant patients in our military population. METHODS: This Institutional Review Board approved retrospective review of patients enrolled in our screening program from 2013-2019 identified patients who failed to obtain a subsequent Low Dose CT scan (LDCT) within 15 months of their prior scan. Attempts were made to contact these patients and elucidate motivations for non-adherence via telephone. RESULTS: Of the 242 patients enrolled, 183 (76%) patients were adherent to the protocol. Significant predictors of non-adherence versus adherence were younger age (P=0.008), female sex (P=0.005), and enlisted officer rank (P=0.03). There was no difference with regards to race, smoking status, pack-years, negative screens, lung-RADS level, or nodule size. 31 (52%) non-adherent patients were contacted, and 24 (77%) reported their reason for non-adherence was lack of follow-up for a LDCT. Twenty (64%) were interested in re-enrollment. Of the total screening cohort, 15 interventions were performed, with lung cancer identified in 5 (2%)-a 67% false positive rate. One stage IV lung cancer was found in a non-adherent patient who re-enrolled. CONCLUSIONS: Lack of perceived contact for follow-up was expressed as the primary reason for non-compliance in our screening program. Compliance is critical to the efficacy of any screening modality, and adherence rates to lung cancer screening may be increased through improved contact with patients via multiple avenues (i.e., phone, email, and letter). There is benefit in contacting non-adherent patients as high rates of re-enrollment are possible.