Surgical outcomes of the systemic-to-pulmonary artery shunt: risk factors of post-operative acute events and effectiveness of regulation of pulmonary blood flow with metal clips.

OBJECTIVES: The aim of this study was to analyze the risk factors for acute events after systemic-to-pulmonary shunt (SPS) and to investigate the effectiveness of pulmonary blood flow regulation with a metal clip. METHODS: The case histories of 116 patients (78 biventricular [BV] and 38 single ventricle [SV] physiology) who underwent SPS between 2010 and 2021 were retrospectively reviewed. Our strategy was to delay SPS until 1 month of age; pulmonary blood flow (PBF) regulation by partial clipping of the graft, if needed. Cases of aortic cross-clamping were excluded from this study. RESULTS: CPB was used in 49 (42%) patients: the median age at SPS was 1 month (2 days to 16 years), and the sternotomy approach in 65. Discharge survival was 98.3% (114/116); hospital death occurred in 1.7% due to coronary ischemia. Inter-stage mortality occurred in 1.7% (shunt thrombosis, 1; pneumonia, 1). Pre-discharge acute events occurred in 7 patients (6.0%): thrombosis 3, pulmonary over-circulation 2, and coronary ischemia 2. Multiple logistic regression analysis revealed that pulmonary atresia with intact ventricular septum (PA/IVS) (p = 0.0253) was an independent risk factor for acute events. Partial clipping of the graft was performed in 24 patients (pulmonary atresia 15) and clip removal was performed by catheter intervention in 9 patients; no coronary ischemic events and graft injury occurred in these patients. CONCLUSION: Surgical outcomes after SPS were acceptable and metal clip regulation of pulmonary blood flow appears to be safe and effective. PA/IVS was still a significant risk factor for acute events.

Outcomes of thoracic endovascular aortic repair using fenestrated stent grafts in patients with thoracic aortic distal arch aneurysms.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is challenging because of anatomical restrictions and the presence of cervical branches. Revascularization of the cervical branch is required when conventional commercial stent grafts are used. TEVAR using fenestrated stent grafts (FSG) often does not require additional procedures to revascularize cervical branches. This study aimed to evaluate the features and initial and midterm outcomes of TEVAR using fenestrated stent grafts. METHODS: From April 2007 to December 2016, 101 consecutive patients underwent TEVAR using fenestrated stent grafts for distal aortic arch aneurysms at a single centre. Technical success, complications, freedom from aneurysm-related death, secondary intervention and aneurysm progression were retrospectively investigated. RESULTS: All the patients underwent TEVAR using fenestrated stent grafts. The 30-day mortality rate was zero. Cerebral infarction, access route problems and spinal cord injury occurred in 4, 3 and 2 patients, respectively. Each type of endoleak was observed in 38 of the 101 patients during the course of the study; 20/38 patients had minor type 1 endoleaks at the time of discharge. The endoleak disappeared in 2 patients and showed no significant change in 8 patients; however, the aneurysm expanded over time in 10 patients. Additional treatment was performed in 8 of the 10 patients with type 1 endoleaks and dilatation of the aneurysm. The rate of freedom from aneurysm-related death during the observation period was 98%. CONCLUSIONS: TEVAR with FSG is a simple procedure, with few complications. Additional treatment has been observed to reduce aneurysm-related deaths, even in patients with endoleaks and enlarged aneurysms. Based on this study, the outcomes of endovascular repair of aortic arch aneurysms using a fenestrated stent graft seem acceptable.

Blood flow analysis with computational fluid dynamics in the left atrium after left atrial plication: a prospective study.

OBJECTIVE: This study aimed to evaluate blood flow stagnation in an enlarged left atrium (LA) and prove that left atrial plication (LAP) could alleviate the stagnation. METHODS: Five patients with chronic atrial fibrillation who underwent mitral valve surgery followed by LAP for an enlarged LA with a ≥ 60-mm diameter were included. We performed computational fluid dynamics (CFD) analysis using preoperative and postoperative computed tomography and four-dimensional flow magnetic resonance imaging. Additionally, computer graphics were used to create virtual left atrial appendage resection (LAAR) images. We performed CFD analysis to assess blood flow stagnation in the LA for three groups: preoperative, LAAR, and LAP. RESULTS: When the average and constant stagnation volumes were both set to 100 preoperatively, the average stagnation volumes of the LAAR and LAP groups were 67.42 ± 18.64 and 35.88 ± 8.20, respectively. The constant stagnation volumes of these groups reduced to 45.01 ± 7.43 and 21.14 ± 7.70, respectively. The LAP group also had significantly lower average and constant stagnation volumes than those in the LAAR group (p = 0.006 and p = 0.033, respectively). CONCLUSIONS: Blood flow stagnation was noted in the LAA and enlarged LA. CFD analysis revealed that LAP for the enlarged LA improved blood flow stagnation more than the virtual LAAR alone. CLINICAL TRIAL REGISTRY NUMBER: UMIN000049923.

[Perioperative Management for Patients with Cardiovascular Diseases in General Thoracic Surgery].

For general thoracic surgeons, perioperative management for the prevention of cardiac complications is important because patients undergoing general thoracic surgery often have risk factors for cardiac diseases. Some risk-scoring systems can estimate a patient's risk of perioperative cardiac complication. Surgery-specific risk for intrathoracic surgery is intermediate. Preoperative evaluation for coronary artery disease should be considered only in high-risk patients based on the risk-scoring system and surgery- specific risk. If coronary artery disease is detected in a preoperative patient, the treatment, such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) should not be preoperatively performed as much as possible, because it requires antithrombotic therapy for at least a couple of months and may cause a delay for general thoracic surgical treatment. In high-risk patients for perioperative coronary artery disease, the 12-lead electrocardiogram is recommended for part of routine clinical care during the early postoperative period. The development of perioperative heart failure after noncardiac surgery is a high risk of operative mortality and hospital readmission. Transthoracic echocardiography should not be routinely performed as a preoperative examination, it can help detect underlying heart failure and valvular diseases and contribute to more appropriate postoperative management. Frequent monitoring of vital signs, oxygen saturation, and chest X-rays are important for the early detection of postoperative heart failure.

Surgical Treatment Outcomes of Patients with Non-Small Cell Lung Cancer and Lymph Node Metastases.

This study aimed to investigate the appropriate subgroups for surgery and adjuvant chemotherapy in patients with non-small-cell lung cancer (NSCLC) and nodal metastases. We retrospectively reviewed 210 patients with NSCLC and nodal metastases who underwent surgery and examined the risk factors for poor overall survival (OS) and recurrence-free probability (RFP) using multivariate Cox proportional hazards analysis. Pathological N1 and N2 were observed in 114 (52.4%) and 96 (47.6%) patients, respectively. A single positive node was identified in 102 patients (48.6%), and multiple nodes were identified in 108 (51.4%). Multivariate analysis revealed that vital capacity < 80% (hazard ratio [HR]: 2.678, 95% confidence interval [CI]: 1.483-4.837), radiological usual interstitial pneumonia pattern (HR: 2.321, 95% CI: 1.506-3.576), tumor size > 4.0 cm (HR: 1.534, 95% CI: 1.035-2.133), and multiple-node metastases (HR: 2.283, 95% CI: 1.517-3.955) were significant independent risk factors for poor OS. Tumor size > 4.0 cm (HR: 1.780, 95% CI: 1.237-2.562), lymphatic permeation (HR: 1.525, 95% CI: 1.053-2.207), and multiple lymph node metastases (HR: 2.858, 95% CI: 1.933-4.226) were significant independent risk factors for recurrence. In patients with squamous cell carcinoma (n = 93), there were no significant differences in OS or RFP between those who received platinum-based adjuvant chemotherapy (n = 25) and those who did not (n = 68), at p = 0.690 and p = 0.292, respectively. Multiple-node metastases were independent predictors of poor OS and recurrence. Patients with NSCLC and single-node metastases should be considered for surgery despite N2 disease. Additional treatment with platinum-based adjuvant chemotherapy may be expected, especially in patients with squamous cell carcinoma.

Sublobar Resection for Non-Small Cell Lung Cancer in Octogenarians: A Prospective, Multicenter Study.

BACKGROUND: Segmentectomy is a good surgical option for peripheral, early, non-small cell lung cancer (NSCLC) ≤2 cm. However, the role of sublobar resection including wedge resection and segmentectomy remains unclear for octogenarians with >2-cm but ≤4-cm early-stage NSCLC, for which lobectomy is a standard treatment. METHODS: By use of a prospective registry, 892 patients aged ≥80 years with operable lung cancer were enrolled at 82 institutions. Of these, we analyzed the clinicopathologic findings and surgical outcomes of 419 patients with NSCLC tumors of 2 to 4 cm during a median follow-up of 50.9 months between April 2015 and December 2016. RESULTS: Five-year overall survival (OS) was slightly but not significantly worse after sublobar resection than after lobectomy in the entire cohort (54.7% [95% CI, 43.2%-93.0%] vs 66.8% [95% CI, 60.8%-72.1%]; P = .09). Multivariable Cox regression analysis of OS revealed that these surgical procedures were not independent prognostic predictors (hazard ratio, 0.8 [0.5-1.1]; P = .16). The 5-year OS was comparable between 192 patients who could tolerate lobectomy but were treated by sublobar resection or lobectomy (67.5% [95% CI, 48.8%-80.6%] vs 71.5% [95% CI, 62.9%-78.4%]; P = .79). Recurrence after sublobar resection and lobectomy was locoregional in 11 (11%) of 97 and in 23 (7%) of 322 patients, respectively. CONCLUSIONS: OS might be equivalent between sublobar resection with a secure surgical margin and lobectomy for selected patients aged ≥80 years with peripheral early-stage NSCLC tumors of 2 to 4 cm who can tolerate lobectomy.

[Analysis of Surgical Margin Recurrence Following Segmentectomy for Early-stage Non-small Cell Lung Cancer].

BACKGROUND: Surgical margin recurrence following segmentectomy is a critical issue because it may have been avoided by lobectomy. METHODS: Between January 2000 and December 2018, we retrospectively investigated 199 patients who underwent segmentectomy for c-StageⅠ non-small cell lung cancer at our hospital. RESULTS: Recurrence occurred in 20 cases, of which 3 cases had surgical margin recurrence. In our previous study, the recurrence risk factor after segmentectomy was radiologic solid tumor size( cut-off value 1.5 cm). Of the 130 patients in the low-risk group with radiologic solid tumor size of less than 1.5 cm, five had any recurrence, three of which had surgical margin recurrence. In the high-risk group with radiologic solid tumor size of 1.5 cm or more, no surgical margin recurrence was observed. Three cases of surgical margin recurrence were accompanied by lepidic components, and the tumors were difficult to identify intraoperatively and were located close to adjacent areas. CONCLUSION: Surgical margin recurrence may be avoided by carefully considering the segments to be resected and improving the method for identifying the intersegmental plane.

[Emergent Treatment for Life-threating Hemoptysis].

Life-threatening hemoptysis results significant airway obstruction, abnormal gas exchange. When a patient presents with life-threatening hemoptysis, the initial steps are to provide adequate oxygenation and ventilation, secure the airway, position the patient lateral decubitus with bleeding side down, and perform initial treatments to control the bleeding. Bronchoscopy is an important early procedure and can be both diagnostic and therapeutic. For patients who are stable, contrast chest computed tomography (CT) provides diagnostic information before angiography. In most cases, initial measures are successful, allowing time for a more detailed diagnostic investigation and generation of a therapeutic plan. For most patients, arteriography is appropriate for identifying and embolizing a responsible lesion. For patients with refractory life-threatening hemoptysis, repeating previous interventions or evaluating for surgery is appropriate. Patients with aneurysms should be evaluated for urgent surgery.

Acute aortic thrombosis in the ascending aorta after cisplatin-based chemotherapy for esophageal cancer: a case report.

BACKGROUND: The risk of thrombus development is considered to be increased by malignant tumors and chemotherapy. In addition, thrombosis of the ascending aorta is rare. We report a case of ascending aortic thrombectomy in a patient with esophageal cancer who developed ascending aortic thrombus after starting neoadjuvant chemotherapy, including operative findings and surgical treatment. CASE PRESENTATION: A 63-year-old man with esophageal cancer was administered chemotherapy comprising cisplatin plus 5-fluorouracil. A week after completing 1 cycle of chemotherapy, computed tomography angiography showed acute aortic thrombosis at the ascending aorta. The risk of embolization appeared high because the thrombosis was floating, so we performed emergency ascending aortic thrombectomy. The postoperative course was good and uncomplicated. A month after this surgery, the patient underwent surgery for esophageal cancer. As of 1 year after the cancer surgery, neither cancer nor thrombosis has recurred. CONCLUSION: We describe a case of acute aortic thrombosis in the ascending aorta after cisplatin-based chemotherapy, that was treated by aortic thrombectomy. The treatment strategy should depend on thrombus location and the condition of the patient, but surgical treatment should be considered where possible to achieve better prognosis.

Contemporary surgical management of complete atrioventricular septal defect with tetralogy of Fallot in Japan.

OBJECTIVES: Complete atrioventricular septal defect with tetralogy of Fallot is a rare and complex heart disease. This study aimed to describe contemporary management approaches for this heart disease and the outcomes. METHODS: Data were obtained from 46 domestic institutions in the Japan Cardiovascular Database (2011-2018). Patients with a fundamental diagnosis of complete atrioventricular septal defect with tetralogy of Fallot, without other complex heart diseases, were included. The primary outcome was operative mortality (30-day or in-hospital mortality). RESULTS: A total of 119 patients underwent initial surgery for a complete atrioventricular septal defect with tetralogy of Fallot during this study period. Primary repair was performed in 40 (34%) patients (primary repair group), and palliative procedure was performed in 79 (66%) patients as part of a planned staged approach (staged group). Forty institutions (87%) experienced at least one case of staged repair. No institution experienced more than or equal to two cases/year on average during the study period. Overall, 11 operative mortalities occurred (9.2%). Operative mortality rates in the primary and staged groups were comparable (p = 0.5). Preoperative catecholamine use, repeat palliative surgeries, and emergency admission were significant risk factors for operative mortality in multivariate analysis (odds ratio, 95% confidence interval: 8.58, [0-0.11]; 12.65, [1.28-125.15]; 8.64, [1.87-39.32, respectively]). CONCLUSIONS: Staged approach for complete atrioventricular septal defect with tetralogy of Fallot was the preferred option. The outcomes of this complex disease were favorable for patients in centers with low cases of complete atrioventricular septal defect with tetralogy of Fallot.

The C-reactive protein to albumin ratio is a prognostic factor for stage I non-small cell lung cancer in elderly patients: JACS1303.

PURPOSE: To establish the prognostic significance of C-reactive protein (CRP) and albumin in octogenarians with non-small cell lung cancer (NSCLC) based on the study of the Japanese Association for Chest Surgery (JACS 1303). METHODS: A total of 618 octogenarians with pathological stage I NSCLC, who underwent pulmonary resection, were included in the analysis. We conducted multivariable Cox regression analysis to evaluate the CRP to albumin ratio (CAR) as a potential prognostic factor. Other clinicopathological factors were also evaluated. RESULTS: The median age was 82 years. Operations included lobectomy (n = 388; 62.8%) segmentectomy (n = 95; 15%), and wedge resection (n = 135; 22%). Pathological stage IA was diagnosed in 380 (61.5%) patients. The 3-year (OS) and cancer-specific survival (CS) rates were 86.7% and 94.6%, respectively. OS was significantly higher for patients with low CAR (< 0.106) than for those with high CAR (≥ 0.106) (hazard ratio = 3.13, 95% confidence interval: 1.99-4.93, p < 0.0001). Univariate analysis identified sex, poor performance status, smoking status, comorbidity, solid tumor, histology, high Glasgow prognostic scale, and high CAR as significant prognostic factors. Multivariate analysis identified only the CAR as a significant prognostic factor for both OS and CS. CONCLUSIONS: Our analysis of the nationwide data demonstrated that the CAR is a useful prognostic factor for elderly patients with stage I NSCLC.

Oncological issues in staging mediastinal lymph node metastasis for left lung cancer.

OBJECTIVE: We aimed to discuss the underlying oncological issues in staging of mediastinal lymph node metastasis in patients with left lung cancer who underwent extended radical lymphadenectomy (ERL). METHODS: This multi-institutional retrospective study analyzed 116 patients with left non-small-cell lung cancer who underwent bilateral paratracheal lymph node dissection (ERL) via median sternotomy. The clinicopathological records of patients with mediastinal lymph node metastasis were examined for prognostic factors, including age, sex, histology, tumor size, cN number, preoperative data, metastatic stations (number and distribution), pT, and adjuvant chemotherapy. RESULTS: Mediastinal lymph node metastases were found in 43 patients, and right paratracheal lymph node metastases (pN3) were found in 13 patients. The 5-year overall survival rate was 25.2% in patients with pN3 tumors (n = 13) and 23.1% in patients with pN2 tumors (n = 30). The prognosis did not differ between patients with pN3 and pN2. Univariate analyses showed that histology, cN, and adjuvant chemotherapy were significant prognostic factors in patients with mediastinal lymph node metastasis. In these 43 patients, cN and adjuvant chemotherapy were significant independent prognostic factors in multivariate analysis. CONCLUSIONS: The prognostic factors for left lung cancer with mediastinal lymph node metastasis were cN status and adjuvant chemotherapy, and not pN status (pN2 or pN3). We hope that the study results, which suggest that there may be no difference in prognosis between pN2 and pN3, would broaden the discussion of oncological issues in the staging of mediastinal lymph node metastasis of left lung cancer.

Prognostic Impact of Mediastinal Lymph Node Dissection in Octogenarians With Lung Cancer: JACS1303.

INTRODUCTION: The prognostic significance of mediastinal lymph node dissection (MLND) in elderly patients with non-small cell lung cancer (NSCLC) remains unclear. This post hoc analysis of a nationwide multicenter cohort study (JACS1303) evaluated the prognostic significance of MLND in octogenarians with NSCLC. MATERIALS AND METHODS: We included 622 octogenarians with NSCLC who underwent lobectomy. The median follow-up duration was 41.1 months. We compared survival and perioperative outcomes between patients who did and did not undergo MLND. RESULTS: In total, 414 (67%) patients underwent MLND (ND2 group), whereas 208 (33%) did not undergo MLND (ND0-1 group). The disease stage was more advanced in the ND2 group than in the ND0-1 group. Disease-free survival was slightly greater in the ND0-1 group with marginal significance (P= .079). In the matched cohort (N = 228), which mainly consisted of patients with clinical stage I disease (96%), there was no significant difference between the 2 groups regarding overall and disease-free survival (P= .908 and P = .916, respectively). Operative time and blood loss were significantly lower in the ND0-1 group than in the ND2 group in the entire cohort (P< .001 and P = .050, respectively) and in the matched cohort (P = .003 and P= .046, respectively). CONCLUSION: Based on a nationwide prospective database, we found limited prognostic impact of MLND, suggesting that MLND can be omitted for octogenarians with early-stage NSCLC.

Maximum Standardized Uptake Value on Positron Emission Tomography is Associated With More Advanced Disease and High-risk Features in Lung Adenocarcinoma.

18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT) has been widely used for preoperative staging of lung adenocarcinomas. The aim of this study was to determine whether a high maximum standardized uptake value (SUVmax) could correlate with pathological characteristics in those patients. We retrospectively reviewed patients with clinical stage 0-IA lung adenocarcinoma who underwent preoperative 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography followed by curative anatomical resection. To identify more advanced disease and high-risk features, representing visceral pleural involvement, pulmonary metastasis, lymph node involvement, and lymphovascular involvement in resected surgical specimens, univariate and multivariate logistic regression analyses were performed. The optimal cutoff point for the SUVmax was determined by receiver operating characteristic analysis. In 2 groups divided according to the cutoff point, the disease-free survivals were calculated and compared using the Kaplan-Meier method and the log-rank test. More advanced disease and high-risk features were identified in 55 (18.9%) of the 291 patients. SUVmax was significantly correlated with more advanced disease and high-risk features, as did the consolidation/tumor ratio on computed tomography. Only 2 (1.2%) of the 169 patients with a SUVmax <3.20 showed more advanced disease and high-risk features, compared with 43.4% of patients with a SUVmax ≥3.20. The disease-free survival was significantly higher in patients with a SUVmax <3.20 than in those with a SUVmax ≥3.20 (P = 0.002). A high SUVmax correlates with more advanced disease and high-risk features in patients with clinical stage 0-IA lung adenocarcinoma. The SUVmax should be considered when deciding treatment strategy in early-stage lung adenocarcinoma.

Valve-sparing aortic root replacement and aortic valve repair for a 2-year-old girl with Loeys-Dietz syndrome.

We report the case of a 2-year-old girl with Loeys-Dietz syndrome complicated by aortic root dilatation and aortic regurgitation. We performed valve-sparing aortic root replacement with reimplantation technique and aortic valve repair using central plication and free-margin reinforcement simultaneously. The postoperative course was uneventful and the latest echocardiography, 5 years after procedure, revealed trivial aortic insufficiency.

Survival of Octogenarians with Early-Stage Non-small Cell Lung Cancer is Comparable Between Wedge Resection and Lobectomy/Segmentectomy: JACS1303.

BACKGROUND: Anatomic resection with lymph node dissection or sampling is the standard treatment for early non-small cell lung cancer (NSCLC), and wedge resection is an option for compromised patients. This study aimed to determine whether wedge resection can provide comparable prognoses for elderly patients with NSCLC. METHODS: The study analyzed the clinicopathologic findings and surgical outcomes during a median follow-up period of 39.6 months for 156 patients with solid dominant (consolidation-to-tumor ratio > 0.5) small (whole tumor size ≤ 2 cm) NSCLC among 892 patients 80 years of age or older with medically operable lung cancer between April 2015 and December 2016. RESULTS: The 3-year overall survival (OS) rates after wedge resection and after segmentectomy plus lobectomy did not differ significantly (86.5 %; 95 % confidence interval [CI], 74.6-93.0 % vs 83.7 % 95 % CI, 74.0-90.0 %; P = 0.92). Multivariable Cox regression analysis of OS with propensity scores showed that the surgical procedure was not an independent prognostic predictor (hazard ratio [HR], 0.84; 95 % CI, 0.39-1.8; P = 0.64). The 3-year OS rates were slightly better after wedge resection for 97 patients who could tolerate lobectomy than after segmentectomy plus lobectomy (89.4 %; 95 % CI, 73.8-95.9 % vs 75.8 %; 95 % CI, 62.0-85.2 %; P = 0.14). The cumulative incidence of other causes for death was marginally higher after segmentectomy plus lobectomy than after wedge resection (P = 0.079). CONCLUSIONS: Wedge resection might be equivalent to lobectomy or segmentectomy for selected patients 80 years of age or older with early-stage NSCLC who can tolerate lobectomy.