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Background: Minimally invasive surgery (MIS) requires intense education and training with structured supervision and feedback. However, a standardized training structure is lacking in Germany. This nationwide survey aimed to assess the current state of minimally invasive surgery (MIS) training and factors impacting surgeons' satisfaction. Methods: Between July and October 2021, an online survey was conducted among general, abdominal, and thoracic surgeons in Germany. The survey collected data on department size, individual operative experience, availability of MIS training equipment and curricula, and individual satisfaction with training. A linear regression analysis was conducted to investigate factors influencing the surgeons' satisfaction with the MIS training. Results: A total of 1008 surgeons participated in the survey, including residents (26.1%), fellows (14.6%), attendings (43.8%), and heads of departments (15.2%). Of the respondents, 57.4% reported having access to MIS training equipment, 29.8% and 26% had a curriculum for skills lab MIS training and intraoperative MIS training, respectively. In multivariate linear regression analysis, strongest predictors for surgeons' satisfaction with skills lab MIS training and intraoperative training were the availability of respective training curricula (skills lab: β 12.572; p < 0.001 & intraoperative: β 16.541; p < 0.001), and equipment (β 5.246; p = 0.012 & β 4.295; p = 0.037), and experience as a first surgeon in laparoscopy (β 12.572; p < 0.001 & β 3.748; p = 0.007). Additionally, trainees and teachers differed in their satisfaction factors. Conclusion: Germany lacks standardized training curricula and sufficient access to MIS training equipment. Trainees and teachers have distinct factors influencing their satisfaction with MIS training. Standardized curricula, equipment accessibility, and surgical experience are crucial for improving surgeons' satisfaction with training. [ABSTRACT FROM AUTHOR]

Abstract Background The learning curve of single-port thoracoscopic lobectomy (SPTL) in lung cancer has been widely studied. However, the efficiency of different experience levels of thoracic surgeons in mastering the learning curve is unknown. Hence, we discuss this issue in depth by using several perioperative parameters and oncological outcomes. Methods A total of 120 consecutive cases of SPTL performed by a senior (STS group) and junior (JTS group) thoracic surgeons were retrospectively analyzed. Operation time, estimated blood loss, and duration of postoperative hospital stay were recorded for cumulative summation (CUSUM) learning curve analysis, while the 5-year survival rate was used for oncological evaluation. Results The CUSUM learning curve of the STS group was y = 0.000106x3 − 0.019x2 + 0.852x − 0.036, with a high R-value of 0.9517. When the number of cases exceeded 33, the slope changed from positive to negative. The CUSUM learning curve of the JTS group was y = 0.000266x3 − 0.04x2 + 1.429 × –0.335, with a high R-value of 0.9644. When the number of cases exceeded 25, the slope changed from positive to negative. The learning curve was divided into two phases (phases 1 and 2). The slope of the JTS group in phase 1 was greater than that of the STS group in phase 1 (p 0.05). In addition, the 5-year survival rate was not significantly different between the two groups (p = 0.72). Conclusion This is the first study to analyze the learning curve of thoracic surgeons with different experience levels in mastering SPTL. Moreover, it is also the first study to include multiple perioperative parameters and overall survival to study how quickly surgeons master the SPTL technique. The junior thoracic surgeon was found to have a shorter learning curve for SPTL.

Background: The learning curve of single-port thoracoscopic lobectomy (SPTL) in lung cancer has been widely studied. However, the efficiency of different experience levels of thoracic surgeons in mastering the learning curve is unknown. Hence, we discuss this issue in depth by using several perioperative parameters and oncological outcomes. Methods: A total of 120 consecutive cases of SPTL performed by a senior (STS group) and junior (JTS group) thoracic surgeons were retrospectively analyzed. Operation time, estimated blood loss, and duration of postoperative hospital stay were recorded for cumulative summation (CUSUM) learning curve analysis, while the 5-year survival rate was used for oncological evaluation. Results: The CUSUM learning curve of the STS group was y = 0.000106x3 − 0.019x2 + 0.852x − 0.036, with a high R-value of 0.9517. When the number of cases exceeded 33, the slope changed from positive to negative. The CUSUM learning curve of the JTS group was y = 0.000266x3 − 0.04x2 + 1.429 × –0.335, with a high R-value of 0.9644. When the number of cases exceeded 25, the slope changed from positive to negative. The learning curve was divided into two phases (phases 1 and 2). The slope of the JTS group in phase 1 was greater than that of the STS group in phase 1 (p < 0.001). Meanwhile, comparisons of various parameters between both groups in phase 2 showed no statistically significant difference (p > 0.05). In addition, the 5-year survival rate was not significantly different between the two groups (p = 0.72). Conclusion: This is the first study to analyze the learning curve of thoracic surgeons with different experience levels in mastering SPTL. Moreover, it is also the first study to include multiple perioperative parameters and overall survival to study how quickly surgeons master the SPTL technique. The junior thoracic surgeon was found to have a shorter learning curve for SPTL. [ABSTRACT FROM AUTHOR]

Objective: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. Methods: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. Results: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). Conclusions: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy. [ABSTRACT FROM AUTHOR]

The aim of this study is to review the reported cases in the literature due to a rare variant of the right vertebral artery (VA) origin of the aorta after the left subclavian artery. We reviewed the literature and provide information about this rare variant, summarizing cases reported (21 similar cases) previously by Google Academic and PubMed screening and discussing the importance of embryological development underlying this variant. Based on our current case and previously reported cases, this abnormality is a very rare finding. In these cases, it is important to understand the abnormal anatomy and embryological basis. This abnormality should be considered during endovascular treatment and-or thoracic surgery for the prevention of injury and complications, and in the case of VA catheterization, which cannot be found during diagnostic cerebral angiography, and also for the prevention of injuries and complications. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to investigate the physiotherapy techniques in the thoracic surgery clinic in Turkey. Materials and Methods: The data of this research was obtained through the online questionnaire created by the authors. The questions in the questionnaire were created by the researcher in parallel with the literature (14 questions). In the questionnaire, descriptive information was asked using multiple-choice question types about chest surgery clinics and applied physiotherapy. A chest surgeon from each participating clinic was asked to respond to the questionnaire. Results: A total of 62 clinics participated in the study. The mean number of monthly operations of these clinics is 0-20 in 51.6%, 21-40 in 19.4%, and 41-60 in 19.4%. 64.5% of the clinics participating in the study perform regular physiotherapy practices to their patients. The clinics that applied pulmonary rehabilitation to their patients, 65% of them additionally performed pulmonary rehabilitation in the preoperative period. The most common applications were early mobilization, airway cleaning techniques, deep breathing exercises, assisted coughing, humidification of the airway, incentive spirometer exercises, forced expiration, and exercise practices. 53.3% of the clinics where routine physiotherapy was administered benefited from assistive devices for pulmonary rehabilitation. Conclusion: Although physiotherapy practices are performed in the thoracic surgery clinic in Turkey, they are not at the desired level. Preoperatively pulmonary rehabilitation practice in thoracic surgery is even rarer. Moreover, the content of pulmonary rehabilitation programs is not standard. The prevalence of evidence-based physiotherapy applications should be increased in thoracic surgery clinics. [ABSTRACT FROM AUTHOR]

Introduction: The pleural cavity is a paired space in the chest between the parietal pleura and the visceral pleura, physiologically filled with a small amount of fluid. In the course of various underlying conditions, such as pneumonia, tumors, trauma, or organ failure, there may be an excessive accumulation of fluid in this space. This condition leads to the development of numerous respiratory symptoms and, in extreme cases, can pose a threat to the patient's life. The aim of this article is to present and analyze various therapeutic methods, with a particular focus on thoracic surgical interventions. Materials and methods: Our clinic annually receives hundreds of patients with pleural effusion under its care. The stage of the disease and its cause often determine the preferred treatment method, and the approach may change depending on the treatment stage. Therapeutic methods include pharmacological agents, respiratory rehabilitation, pleural puncture, chest tube drainage, video-assisted thoracoscopy, chemical and mechanical pleurodesis, decortication, and others. This article analyzes these methods in terms of their possibilities and limitations. Results: Each therapeutic method for pleural effusion has its pros and cons. Although surgical methods yield rapid results after their application, the patient's management should not be limited exclusively to them. Often, the spectacular therapeutic effects come with consequences for the patient, such as pain, local complications, and the inability to function independently in the postoperative period. Conclusions: The care of patients with pleural effusion requires collaboration among various specialists, and therapeutic methods complement each other, with their significance changing throughout the course of the disease. The thoracic surgeon's approach to treatment depends on the patient's condition and the underlying disease. Regardless of the scenario, respiratory rehabilitation is an extremely important tool that can act on both the cause and symptoms of the disease, as well as support recovery after thoracic surgical procedures and treat their complications. [ABSTRACT FROM AUTHOR]

The respiratoy centre in Hospital of Winsen has grown successfuly over the last decade. In our daily work we see the need and the difficulties in an interdisciplinary approach for the benefit of our patients. Out team of physicians, respiratory therapists, physiotherapists, speech therapists and thoracic surgeons needs routines to optimize the communication in finding the right diagnosis and the best treatment for our patients. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is frequent in patients scheduled for implantation of a left ventricular assist device (LVAD) and associated with increased mortality. Although several risk models for the prediction of postoperative renal replacement therapy (RRT) have been developed for cardiothoracic patients, none of these scoring systems have been validated in LVAD patients. A retrospective, single center analysis of all patients undergoing LVAD implantation between September 2013 and July 2016 was performed. Primary outcome was AKI requiring RRT within 14 days after surgery. The predictive capacity of the Cleveland Clinic Score (CCS), the Society of Thoracic Surgeons Score (STS), and the Simplified Renal Index Score (SRI) were evaluated. 76 patients underwent LVAD implantation, 19 patients were excluded due to preoperative RRT. RRT was associated with a prolonged ventilation time, length of stay on the ICU and 180 day mortality (14(60.9%) vs 6(17.6%), P <.01). Whereas the Thakar Score (7.43 ± 1.75 vs 6.44 ± 1.44, P =.02) and the Mehta Score (28.12 ± 15.08 vs 21.53 ± 5.43, P =.02) were significantly higher in patients with RRT than in those without RRT, the SRI did not differ between these groups (3.96 ± 1.15 vs 3.44 ± 1.05, P =.08). Using ROC analyses, CCS, STS, and SRI showed moderate predictive capacity for RRT with an AUC of 0.661 ± 0.073 (P =.040), 0.637 ± 0.079 (P =.792), and 0.618 ± 0.075 (P =.764), respectively, with comparable accuracy in the Delong test. Using univariate logistic regression analysis, only the De Ritis Ratio (OR 2.67, P =.034) and MELD (OR 1.11, P =.028) were identified as predictors of postoperative RRT. Risk scores which are predictive in general cardiac surgery cannot predict RRT in patients after LVAD implantation. Therefore, it seems to be necessary to develop a specific risk score for this patient population. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Venous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article. METHODS A 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies. RESULTS In total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally. CONCLUSIONS There is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed. [ABSTRACT FROM AUTHOR]

Background: There are disparate data on the outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) compared with younger patients. The purpose of this study is to determine whether the Society of Thoracic Surgeons (STS) score can be used to identify the subset of nonagenarians that are at a significantly higher risk for poor postoperative outcomes after TAVR.Methods: A total of 425 patients above the age of 80 underwent elective TAVR between 12/2013 and 2/2018 and were included in this study. Patients were deemed intermediate or high risk based on an STS predicted the risk of surgical mortality score of 3% to 8% and more than 8%, respectively. Differences in postoperative outcomes and/or 6-month mortality between intermediate and high-risk octogenarians and nonagenarians were compared.Results: Of the 425 patients, 112 (26.4%) patients were nonagenarians, and 313 (73.6%) patients were octogenarians. Fifty-four (48.2%) of the nonagenarians were stratified as high-risk, while 78 (24.9%) of the octogenarians were stratified as high-risk. There were no statistically significant differences in the composite outcomes between intermediate-risk nonagenarians and intermediate-risk octogenarians. In contrast, high-risk nonagenarians were significantly more likely to experience the composite outcome of major perioperative complications and/or 6-month mortality as compared to high-risk octogenarians.Conclusion: Intermediate-risk nonagenarians undergoing TAVR have similar postoperative outcomes compared to intermediate-risk octogenarians. However, high-risk nonagenarian patients undergoing TAVR experience significantly poorer outcomes compared to their octogenarian counterparts. Judicious patient selection for TAVR in this subgroup of patients is therefore warranted. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to simulate and compare the healthcare and economic outcomes associated with routine use of intraoperative transoesophageal echocardiography (TOE) in patients undergoing cardiac surgery with those associated with a scenario where TOE is not routinely used.Methods: The impact of TOE on surgical decision-making was estimated through a systematic literature review. Individual short-term morbidity and mortality estimates were generated by application of the Society of Thoracic Surgeons risk calculator. Long-term event rates, unit costs, and utility weights were sourced from published literature and expert opinion. A discrete-event simulation model was then constructed to simulate both the in-hospital and post-discharge outcomes for patients undergoing cardiac surgery. Robustness of the base case results was examined through deterministic and probabilistic sensitivity analyses. An incremental cost-effectiveness ratio of €30 000 per quality-adjusted life-year gained was assumed to represent acceptable cost-effectiveness.Results: Routine use of intraoperative TOE was associated with lower costs and higher benefits per patient, which indicates that use of TOE is a dominant strategy. The intervention resulted in the avoidance of 299 cardiac complications, 20 strokes, and 11 all-cause deaths per 10 000 patients. Routine intraoperative TOE was associated with an increased occurrence of bleeding owing to more valvular surgery and subsequent long-term anticoagulation.Conclusions: Routine intraoperative TOE is a cost-effective procedure for patients undergoing cardiac surgery, leading to lower overall costs. It was associated with a decrease in long-term complications including stroke, cardiac complications, and death, although there was a slight increase in extracranial bleeding events. [ABSTRACT FROM AUTHOR]

Background& Objectives: Primary chest wall sarcomas are rare and therapeutically challenging tumors. Herein we report the outcomes of a surgery-based multimodality therapy for these pathologies over an 11-year period. In addition, we present a case that illustrates the surgical challenges that extensive chest wall resection may pose.Methods: Using the Society of Thoracic Surgeons general thoracic surgery database, we have prospectively collected data in our institute on all patients undergoing chest wall resection and reconstruction for primary chest wall sarcomas between June 2008-October 2019.Results: We performed 28 surgical procedures on 25 patients aged 5 to 91 years (median age 33). Eleven tumors were bone- and cartilage-derived and 14 tumors originated from soft tissue elements. Seven patients (7/25, 28%) received neo-adjuvant therapy and 14 patients (14/25, 56%) received adjuvant therapy. The median number of ribs that were resected was 2.5 (range 0 to 6). In 18/28 (64%) of surgeries, additional skeletal or visceral organs were removed, including: diaphragm [1], scapula [2], sternum [2], lung [2], vertebra [1], clavicle [1] and colon [1]. Chest wall reconstruction was deemed necessary in 16/28 (57%) of cases, polytetrafluoroethylene (PTFE) Gore-Tex patches was used in 13/28 (46%) of cases and biological flaps where used in 4/28 (14%) of cases. R0, R1 and R2 resection margins were achieved in 19/28 (68%), 9/28 (32%) and 0/28 (0%) of cases, respectively. The median follow up time was 33 months (range 2 to 138). During the study period, disease recurred in 8/25 (32%) of patients. Of these, 3 were re-operated on and are free of disease. At date of last follow up, 5/25 (20%) of patients have died due to their disease and in contrast, 20/25 (80%) were alive with no evidence of disease.Conclusions: Surgery-based multimodality therapy is an effective treatment approach for primary chest wall sarcomas. Resection of additional skeletal or visceral organs and reconstruction with synthetic and/or biological flaps is often required in order to obtain R0 resection margins. Ultimately, long-term survival in this clinical scenario is an achievable goal. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the impact of preoperative angiotensin-converting enzyme inhibitor (ACEi) exposure on outcomes of coronary artery bypass grafting (CABG).Methods: Isolated CABGs from January 2010 to January 2018 at a single institution were included. Primary stratification was based on exposure to an ACEi within 48-hours of CABG. Propensity-matching with a 1:1 ratio was performed to generate cohorts with comparable baseline characteristics. Primary outcomes included operative mortality and morbidity rates as well as prolonged intensive care unit (ICU) stay. Secondary outcomes included hospital readmission.Results: Five-thousand two hundred seventy propensity-matched patients underwent isolated CABG. Baseline characteristics were comparable between those exposed and unexposed to ACEi, with a Society of Thoracic Surgeons predicted risk of mortality of 2.4% in each group (P = .98). Rates of postoperative renal failure (5.0% vs 8.2%; P = .002), new-onset dialysis (1.2% vs 2.2%; P = .004), and prolonged ventilation (7.0% vs 13.4%; P < .0001) were higher in patients without ACEi exposure. The rates of prolonged ICU stay were similar (25.8% vs 27.7%; P = .127). ACEi exposed patients had lower unadjusted (1.7% vs 2.8%; P = .009) and risk-adjusted hazards for mortality at 30-days (hazard ratio, 0.59; 95% confidence interval, 0.40, 0.88; P = .01). Overall readmission rates were similar. Similar findings persisted when limiting the analysis to CABGs performed with the use of cardiopulmonary bypass.Conclusions: This study of 5270 propensity-matched patients suggests that ACEi can safely be continued until the time of CABG without an adverse impact on clinical outcomes, and in fact, may confer an early survival advantage and reduced postoperative renal failure rates. [ABSTRACT FROM AUTHOR]

Objective: Minimal invasive mitral valve surgery (MIMVS) has become a commonly used approach for mitral valve surgery. Several techniques of myocardial preservation were described in patients undergoing MIMVS. We aim to evaluate preservation technique and short term outcomes.Methods: A retrospective analysis of patients who underwent isolated MIMVS and were included in the Society of Thoracic Surgeons (STS) database.Results: The final cohort included 4976 patients. Mean age was 63.1 years (SD, 12.5) and 42.6% were females. Antegrade delivery method (71.3% of the patients) was the most common, follow by antergrade/retrograde (19.9%). Blood, crystalloid solution, and combination of blood-crystalloid were used in 62.4%, 13.2%, and 13.7%, respectively. In multivariate analysis, cardioplegia technique was associated with mortality (P = .011), pleural effusion (P = .045), and length of ICU stay (P < .001). Antegrade-crystalloid (OR, 3.37; 95%CI, 1.70-6.68) and antegrade/retrograde-blood/crystalloid (OR, 3.28; 95%CI, 1.15-9.38) were associated with increased risk for mortality compared with antegrade-blood cardioplegia. Data on postoperative ejection fraction (EF), CPK-MB, and Troponin was available only in 30%, 9%, and 5% of the patients, respectively, and were not included in the analysis.Conclusions: Ante-grade-blood was the most common preservation technique in MIMVS. Ante-grade-crystalloid and ante-grade/retrograde-blood/crystalloid are associated with increased risk for mortality. The results suggest that using crystalloid solutions for cardioplegia should be carefully considered. The STS database as a source for MIMVS outcome analysis is lacking, both in detailed specification of different surgical technique aspects, and in actual data collection of already existing categories. [ABSTRACT FROM AUTHOR]

Background: The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery.Methods: The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure.Results: The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions.Conclusion: Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Transcatheter mitral valve repair (TMVr) for the treatment of mitral regurgitation (MR) is a complex procedure that requires development of a unique skillset.Objectives: The purpose of this study was to examine the relationship between operator experience and procedural results of TMVr.Methods: TMVr device procedures from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry were analyzed with operator case number as a continuous and categorical (1 to 25, 26 to 50, and >50) variable. Outcomes of procedural success, procedural time, and in-hospital procedural complications were examined. The learning curve for the procedure was evaluated using generalized linear mixed models adjusting for baseline clinical variables.Results: All TMVr device procedures (n = 14,923) performed by 562 operators at 290 sites between November 2013 and March 2018 were analyzed. Optimal procedural success (≤1+ residual MR without death or cardiac surgery) increased across categories of operator experience (63.9%, 68.4%, and 75.1%; p < 0.001), while procedural time and procedural complications decreased. Acceptable procedural success (≤2+ residual MR without death or cardiac surgery) also increased with operator experience, but the differences were smaller (91.4%, 92.4%, and 93.8%; p < 0.001). These associations remained significant in adjusted, continuous variable analyses. Visual inflection points in the learning curves for procedural time, procedural success, and procedural complications were evident after approximately 50 cases, with continued improvements observed out to 200 cases.Conclusions: For TMVr device procedures, operator experience was associated with improvements in procedural success, procedure time, and procedural complications. The effect of operator experience was greater when considering the goal of achieving 1+ residual MR. [ABSTRACT FROM AUTHOR]

Background: Aortic stenosis (AS) is a common valvular abnormality and transcatheter aortic valve implantation (TAVI) is being increasingly used to treat patients considered too high risk for conventional surgery. We aimed to assess the prevalence of comorbid conditions in patients undergoing TAVI using the Charlson Comorbidity Index (CCI) and to assess their impact on clinical and procedural outcomes.Methods: We analysed 158 patients who underwent a TAVI at our institution between June 2009 and September 2015 to define their co-morbid burden as measured with CCI, and study its impact on procedural characteristics and mortality at 30 days.Results: One hundred fifty-eight (158) patients with a mean age of 82±8years and a mean CCI score of 2.67 underwent a TAVI. Only 12/158 patients had a CCI of 0. The commonest cardiovascular comorbidities were previous myocardial infarction (24%), congestive heart failure (15%) and diabetes mellitus (23%) whilst the commonest non-cardiovascular comorbidities were renal disease (46%) and chronic obstructive pulmonary disease (COPD) (29%). After multivariable adjustment, CCI was not independently associated with adverse clinical outcomes. The addition of CCI to scoring systems such as Logistic EuroScore (LES) and Society of Thoracic Surgeons (STS) risk models improved the area under the curve from 0.75 (95%CI: 0.44-1.00) and 0.83 (95%CI: 0.64-1.00) to 0.78 (95%CI: 0.53-1.00) and 0.89 (95%CI: 0.78-1.00) respectively.Conclusions: The burden of comorbid conditions in patients undergoing TAVI is significant. The CCI score was not independently associated with a higher risk of death but can be useful in addition to LES and STS risk models in informing decision making on the selection of patients for TAVI. [ABSTRACT FROM AUTHOR]

Purpose: We investigated the outcomes of patients who underwent Transcatheter Aortic Valve Replacement (TAVR) with and without Balloon Aortic Valvuloplasty (BAV) using the SAPIEN 3 (S3) valve.Methods: All patients who underwent TAVR using S3 valve were included. The primary outcomes were the incidence of stroke and significant paravalvular leak (PVL). Secondary outcomes were the incidence of mortality, balloon post dilation, and need for permanent pacemaker.Results: From July-2014 to April-2018, 34 (9%) patients underwent BAV prior to TAVR and 344 (91%) patients underwent direct TAVR without BAV using the S3 valve. The Society of Thoracic Surgeons (STS) risk score was similar between two groups; 5.8 ± 3.5 in no BAV group and 5.4 ± 3.3 in BAV group, p = 0.53. After TAVR, 6 (1.7%) patients in no BAV group but no patient in BAV group developed stroke (p = 1.0). No patient had severe PVL and only 5 patients (1.3%) had moderate PVL at 30-day; 4 (1.2%) in no BAV group and 1 (2.9%) in BAV group (p = 0.38). Forty-six patients (13.4%) in the no BAV group and 4 (11.8%) patients in the BAV group needed balloon post dilation (p = 1.0). Six (1.6%) patients died during hospitalization, all in the no BAV group (p = 1.0). Forty-five (11.9%) patients needed new pacemaker implantation; 44 (12.8%) patients in no BAV group and 1 (2.9%) patient in BAV group (p = 0.1). Two-year survival rate was 85% in no BAV group and 84% in BAV group (p = 0.46).Conclusions: TAVR using S3 valves is associated with very low rates of post-TAVR stroke and significant PVL. Outcomes of direct TAVR are similar to the outcomes of TAVR with BAV, without an increased rate of stroke, significant PVL, or balloon post dilation. [ABSTRACT FROM AUTHOR]

Concurrent chemotherapy and radiotherapy (cCRT) is considered the standard treatment of locally advanced non-small cell lung cancer (LA-NSCLC). Unfortunately, management is still heterogeneous across different specialists. A multidisciplinary approach is needed in this setting due to recent, promising results obtained by consolidative immunotherapy. The aim of this survey is to assess current LA-NSCLC management in Italy. From January to April 2018, a 15-question survey focusing on diagnostic/therapeutic LA-NSCLC management was sent to 1,478 e-mail addresses that belonged to pneumologists, thoracic surgeons, and radiation and medical oncologists. 421 answers were analyzed: 176 radiation oncologists, 86 medical oncologists, 92 pneumologists, 64 thoracic surgeons and 3 other specialists. More than a half of the respondents had been practicing for >10 years after completing residency training. Some discrepancies were observed in clinical LA-NSCLC management: the lack of a regularly planned multidisciplinary tumor board, the use of upfront surgery in multistation stage IIIA, and territorial diffusion of cCRT in unresectable LA-NSCLC. Our analysis demonstrated good compliance with international guidelines in the diagnostic workup of LA-NSCLC. We observed a relationship between high clinical experience and good clinical practice. A multidisciplinary approach is mandatory for managing LA-NSCLC. [ABSTRACT FROM AUTHOR]

Mediastinitis is a rare, progressive, and destructive infectious process due to cervical or odontogenic infections, which, if not diagnosed early, may lead to several complications, including airway involvement and even an imminent risk of death. Herein, we report an unusual case of a 37-year-old male with a bilateral submandibular hard swelling after the left third molar extraction. After surgical intervention with submandibular drainage and antibiotic therapy, the infection persisted without explanation, since the patient was not hypertensive, did not have diabetes mellitus or sexually transmitted infections such as HIV or syphilis, and did not smoke or drink alcoholic beverages. A thoracic surgeon then intervened, treating the mediastinitis surgically by drainage, thus obtaining a significant improvement of the patient's health. Mediastinitis is a serious condition. Clinicians and maxillofacial surgeons should be alert to make an immediate diagnosis and select the appropriate treatment in order to prevent worsening of the patient's clinical condition. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Multi-arterial bypass grafting with bilateral internal thoracic (BITA-MABG) or radial (RA-MABG) arteries improves long-term survival, but its increased complexity raises perioperative safety concerns. We compared perioperative outcomes of RA-MABG and BITA-MABG using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD). METHODS We analysed the 2004–2015 BITA-MABG and RA-MABG experience in STS-ACSD. Primary end points were operative mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios [AOR (95% confidence interval)] were derived via multivariable logistic regression. Sensitivity analyses were done in patient sub-cohorts and based on institutional BITA-utilization rates (<5%, 5–10%, 10–20%, 20–40% and >40%). RESULTS Eighty-five thousand nine hundred five RA-MABG (82.5% men; 61 years) and 61 336 BITA-MABG (85.1% men; 59 years) patients were analysed; 41.6% of BITA-MABG and 27.3% of RA-MABG cases came from institutions with low MABG utilization rates (<10%). Unadjusted OM was equivalent for both techniques (BITA-MABG versus RA-MABG: 1.3% vs 1.2%, P  = 0.79), while DSWI was lower for RA-MABG (1.0% vs 0.6%, P  < 0.001). RA-MABG was associated with lower adjusted OM [AOR = 0.80 (0.69–0.96)] and DSWI [AOR = 0.39 (0.32–0.46)]. Sensitivity analyses confirmed robustness of these findings. Equivalent outcomes were observed at high BITA-use institutions where BITA cases comprised >20% of all cases for OM and ≥40% for DSWI. CONCLUSIONS This analysis of the STS-ACSD showed that RA-MABG is a generally safer form of multi-arterial coronary artery bypass grafting surgery. However, this advantage is mitigated at institutions with substantial BITA experience. [ABSTRACT FROM AUTHOR]

Background: Many recent reports have encouraged the use of VATS in the management stage II empyema. The technical difficulty caused by pleural adhesions, is not considered an obstacle hindering the procedure anymore. Furthermore, thoracic surgeons around the world are increasingly trying to manage patients with stage III empyema solely using VATS. This current study aims to compare the results of surgical decortication for empyema using the VATS and thoracotomy approaches. Patients and Methods: This prospective comparative non-randomized clinical study was carried out in the Department of Cardiothoracic Surgery of Kasr el Ainy faculty of medicine Cairo University from September 2016 till May 2018. The study encompassed 60 patients who had empyema and scheduled for surgery. The study patients were divided into 2 matching groups. Group A (thoracoscopic decortication), and group B (open decortication). All were studied for early outcome. Results: In the VATS group (group A) the conversion rate to open thoracotomy was 33.3%. The mean operative time was similar in to the thoracotomy group (group B). The successful achievement of fully expanded lungs was higher in the VATS group (93.3% vs 80%, p=0.129). VATS also showed less pain (2.27 ± 1.64 vs 4.27 ± 2.05, p=0.001*), less wound complications (0% vs 13.3%, p=0.038*), and shorter hospital stay (5.27 ± 3.90 vs 8.07 ± 5.36, p=0.003*). Conclusion: We concluded that VATS is safely feasible in the organized, late stage III pleural empyema, and thus should be considered as the preferred approach when addressing chronic empyema, as long as complete re-expansion of the lung can be achieved. Moreover, conversion to the open technique should be done whenever necessary, to avoid undesired postoperative morbidity. [ABSTRACT FROM AUTHOR]

Over two decades, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) cardiac surgery database program has evolved from a single state-based database to a national clinical quality registry program and is now the most comprehensive cardiac surgical registry in Australia. We report the current structure and governance of the program and its key activities. [ABSTRACT FROM AUTHOR]

Summary: Background: Mucormycosis portends a poor prognosis with mortality rates ranging from 50% to 70% in pulmonary mucormycosis (PM) and up to 95% in disseminated disease. However, detailed outcomes data have been lacking. It remains unknown how to identify patients who would benefit from surgical resection. Objectives: We present our experience with patients undergoing surgical resection for PM, including an analysis of factors affecting postoperative survival. We also describe a thoracic surgeon's approach through illustrative cases. Patients/Methods: We conducted a single‐centre retrospective study of all adult patients with PM who received antifungal therapy and underwent surgical resection or who received antifungal therapy alone at Stanford between January 2004 and June 2018. Results: Twelve patients received antifungal therapy and underwent surgical resection and 13 patients received antifungal therapy alone. From infection onset to death (or right‐censoring if still alive), patients who underwent surgical resection had a median survival of 406 days (mean, 561.3; range, 22‐2510), and patients who received antifungal therapy alone had a median survival of 28 days (mean, 66.7; range, 8‐447). In patients who underwent surgical resection, median postoperative survival time was 154 days (range, 11‐2495), in‐hospital mortality was 16.7%, and 1‐year mortality was 50.0%. Age, primary disease, ASA status, extrapulmonary dissemination, laterality, multilobar involvement, number of lesions, largest lesion size, platelet count, surgical approach, type of resection or extent of resection were not significantly associated with postoperative survival. Conclusions: Surgical resection significantly increases survival and should be strongly considered for selected patients with PM. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES: Minimum volume standards for thoracic surgical procedures have been advocated to improve outcomes. However, such standards are controversial within the thoracic surgery literature, and the methodology to determine cut points between high- and low-volume hospitals has been criticized. Furthermore, while multiple studies have examined hospital volume and its relationship with outcomes, there have been very few attempts to study this issue from the perspective of the individual thoracic surgeon. The aim of this study was to determine if surgeon volume is associated with differences in outcomes using a large state-wide database. METHODS: The study utilized the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data for analysis. Patients who underwent major lung resections including sublobar resection, lobectomy and pneumonectomy from 1995 to 2014 were included and were categorized into 3 subgroups based on the extent of resection. Patient characteristics included age, gender, race, insurance and comorbidities. Surgeon information was obtained by using a unique identifier. Average annual surgical volumes of sublobar resection, lobectomy and pneumonectomy were calculated separately and grouped into 3 categories based on the tertiles. Demographic data and comorbidities were compared between the various volume groups to analyse the resulting complications. Primary outcomes were in-hospital mortality and 30-day readmission. RESULTS: There were a total of 99 576 major lung resections performed between 1995 and 2014 in the SPARCS database. Among these, the majority were wedge or segmental resections (n  = 54 953, 55.2%) followed by lobectomy (n  = 40 421, 40.6%) and pneumonectomy (n  = 4202, 4.2%). In-hospital mortality was significantly greater for low-volume surgeons compared to high-volume surgeons for all resection groups. Additionally, low-volume surgeons had higher 30-day readmission rates for patients undergoing lobectomy and pneumonectomy. However, low-volume surgeons as a group were more likely to operate on black patients and patients with Medicaid, and black race was an independent predictor of mortality across all resection groups. The vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group. CONCLUSIONS: Low-volume surgeons had higher rates of in-hospital mortality compared to their high-volume counterparts. However, the vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group, and low-volume surgeons operated on higher percentages of black patients. These findings suggest that minimal volume standards would significantly impact the current delivery of thoracic surgery in the US. [ABSTRACT FROM AUTHOR]

Introduction: In 2012, the Korean central government selected trauma centers to provide effective treatment and reduce preventable mortality in severe trauma patients. General surgeons, thoracic surgeons, orthopedists, and neurosurgeons play pivotal roles in trauma centers, as most trauma patients require orthopedic procedures. This study aimed to underscore the importance of trauma orthopedic specialists (TOSs) by comparing treatment outcomes between a TOS and general orthopedists.Patients and Methods: Orthopedic trauma patients with injury severity scores > 15 points, admitted to level 1 trauma centers between March 2015 and December 2016, were divided into the TOS group (treated by 1 orthopedic trauma specialist who treats trauma patients with no limitation in the joint of specialization) and the general orthopedist group (GOG; treated by several general orthopedists who manage both trauma and disease but are each specialized in a certain joint). Emergency room response time, triage time, surgical preparation time, number of surgeries per patient, intensive care unit (ICU) duration, complications, and mortality were retrospectively analyzed.Results: Among 272 patients, 52 were treated by a TOS and 220 were treated by several general orthopedists. For the TOS group and the GOG, the average emergency room response time was 8 and 32 min; average triage time, 27 and 162 min; average surgical preparation time, 141 and 350 min; average number of surgeries per patient, 1.9 and 2.7; and average ICU duration, 8.5 and 12.2 days, respectively. The TOS group saved $2700 per patient. No statistical differences were found in complications and mortality between the 2 groups.Conclusions: TOSs can provide rapid treatment to trauma patients and systemically participate in collaborative treatment with other specialists in a trauma center. As treatment provided by a TOS can also reduce the ICU duration, TOSs can play an important role in rapid rehabilitation and cost reduction for trauma patients. [ABSTRACT FROM AUTHOR]

Objective: Evidence in other surgical subspecialties suggests patients traveling farther to undergo surgery have worse outcomes. We sought to determine the impact of travel distance and travel beyond closest center on outcomes after valve surgery.Methods: Patients who underwent valve surgery ±CABG with a Society of Thoracic Surgeons (STS) predicted risk and zip code were extracted from a statewide STS database (2011-016). Patients were stratified by those receiving care greater than or equal to 20 miles from the closest surgical center (Traveler) or at the closest center (Non-Traveler). Multivariate logistic regression assessed the effects of travel distance and traveler status on mortality and major morbidity adjusted for STS predicted risk, median income by zip code, and payer status.Results: Median travel distance for all patients (n = 4765) was 19 miles and after risk-adjustment increasing distance was associated with reduced operative mortality (odds ratio [OR], 0.94 [0.89-1.00], P = .049) with no impact on major morbidity. Travelers (445 patients, 9.3%) had lower median income, higher self-pay and reoperative status, but similar urgent/emergent status and STS risk as Non-Travelers. Travelers had lower operative mortality (1.6% vs 4.3%, P = .005) which remained statistically lower after risk-adjustment (OR, 0.32 [0.14-0.75], P = .009). This mortality difference was particularly pronounced in patients with postoperative complications (3.1% vs 7.9%, P = .005).Conclusions: Contrary to other surgical subspecialties, farther travel distance and bypassing the nearest surgical center were associated with lower rates of operative mortality and failure to rescue. Either referral patterns or financials reasons may result in Travelers ending up at high performing centers that prevent escalation of complications. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to assess real-world clinical outcomes of transcatheter aortic valve replacement (TAVR) in Japan.Background: Data are limited concerning procedural safety and valve performance following TAVR in Japanese. A program by an on-site proctor and procedure screening system was applied during TAVR introduction.Methods: We consecutively enrolled 1613 patients who underwent TAVR using data from the Optimized CathEter vAlvular iNtervention (OCEAN) Japanese registry, which consists of 14 centers. Baseline characteristics and procedural outcomes including combined early 30-day non-safety, and mortality rates were assessed among 4 groups, divided into quartiles (Q1-Q4).Results: Most patients were women (70.4%), elderly (84.4 ± 5.1 years), and had a median Society of Thoracic Surgeons score of 6.7(4.7-9.5). The overall 30-day mortality, combined early non-safety, and cumulative 1-year mortality rates were 1.7%, 15.1%, and 11.3%, respectively. Thirty-day mortality was not affected by center experience differences divided into quartiles (1.0%, 2.0%, 2.5%, 1.5%, p = 0.404), whereas 30-day early safety was significantly improved (19.1%, 17.9%, 14.6%, 8.9%, p < 0.001). Thirty-day mortality was 0% under transfemoral on-site proctor. Cox-regression multivariate analysis revealed that male sex, clinical frailty scale, New York Heart Association class, creatinine, albumin, hemoglobin, liver disease, and non-transfemoral approach were independent predictive factors of increased midterm mortality risk.Conclusions: Owning to the global supporting system in Japan, excellent early and midterm outcomes have been achieved to overcome the learning curve of the newly introduced TAVR procedure. [ABSTRACT FROM AUTHOR]

Objectives: To measure and analyse various factors affecting radiation exposure (RE) to surgeons during percutaneous nephrolithotomy (PCNL). Patients and Methods: A total of 212 patients who underwent PCNL were analysed. Informed consent was obtained from all enrolled patients. Ultrasonography/fluoroscopy guided punctures were done. The tract was dilatated and sheath placement done after which the procedure was completed in a routine fashion. A JJ or ureteric catheter or percutaneous nephrostomy (PCN) tube was placed as per the merit of the case. A digitalised mobile surgical C‐arm image‐intensifier system was used in all cases. RE was determined using a pen dosimeter worn outside the lead apron of the surgeon at the level of the chest for uniformity and was recorded on a per case basis at the end of the procedure. Data were recorded for analysis with respect to relevant parameters. Multivariate regression analysis was used to identify various parameters which affect RE (mSv). Results: The parameters analysed included: age, number and size of stones, body mass index (BMI) of patients, Hounsfield unit of stone (HU), degree of hydronephrosis, number of tracts, mode of access to pelvicalyceal system (PCS), sheath size (F), operative time (min), placement of a JJ or ureteric catheter or PCN tube, and kV used for exposure. There was a significant statistical relationship between stone volume (P < 0.001), number of tracts (P < 0.001), mode of access to PCS (P = 0.001), and sheath size (P = 0.002), with RE. The HU had a negative relationship, with a decrease in HU causing increased RE (P = 0.002). BMI, number of stones, degree of hydronephrosis, operative time and placement of a JJ or ureteric catheter or PCN tube did not have any correlation with RE in our study. Conclusion: The mean (SD) RE per procedure was 0.21 (0.11) mSv. Increasing size and low HU of stone, increasing number of tracts, fluoroscopic access to PCS, increasing sheath size and kV were found to increase RE. Although the exposure levels are within safety limits, serial monitoring and constant vigilance are mandatory to inform surgeons. [ABSTRACT FROM AUTHOR]

Download slide Download slide OBJECTIVES Although extracorporeal membrane oxygenation (ECMO) represents a rapidly evolving treatment option in patients with refractory heart or lung failure, survival remains poor and appropriate risk stratification challenging because established risk prediction models have not been validated for this specific population. METHODS This observational single-centre registry included a total of 240 patients treated with venoarterial ECMO therapy following cardiovascular surgery and analysed the discriminatory power of the European System of Cardiac Operative Risk Evaluation (EuroSCORE) additive, the EuroSCORE II, the Sequential Organ Failure Assessment (SOFA) score, the Simplified Acute Physiology Score (SAPS) II, the SAPS III, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage renal failure (RIFLE) classification, the survival after venoarterial ECMO (SAVE) score, the prEdictioN of Cardiogenic shock OUtcome foR AMI patients salvaGed by VA-ECMO (ENCOURAGE) score and the Society of Thoracic Surgeons (STS) risk model for outcome prediction. RESULTS During a median follow-up time of 37 months (interquartile range 19–67), 65% of the patients died. Only the SAVE score and the SAPS II were significantly associated with the 30-day mortality rate with a hazard ratio (HR) of 1.06 [95% confidence interval (CI) 1.02–1.11; P  = 0.002] for the SAVE score and an HR of 1.02 (95% CI 1.01–1.03; P  = 0.004) for the SAPS II with a modest discriminatory power displayed by a C-index of 0.61 and 0.57, respectively. Seven out of 10 scoring systems revealed significant association with long-term mortality, with the SAVE score and the SAPS II remaining the strongest predictors of long-term mortality with an HR of 1.06 (95% CI 1.03–1.09; P  < 0.001, C-index 0.61) for the SAVE score and an HR of 1.02 (95% CI 1.01–1.03; P  < 0.001, C-index 0.58) for the SAPS II. CONCLUSIONS Risk assessment based on established risk models in patients with ECMO remains difficult. Only the SAPS II and the SAVE score were exclusively found to be suitable for short- and long-term outcome prediction in this specific vulnerable patient population. [ABSTRACT FROM AUTHOR]

Background: Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally-invasive CABG (MICABG) may reduce perioperative morbidity. Previous results demonstrate improved perioperative outcomes; however, adoption has been limited.Methods: The Society of Thoracic Surgeons (STS) database and electronic medical record at a single institution were reviewed for isolated left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between 2011 and 2018. Patients were grouped on the basis of operative approach, comparing sternotomy to non-sternotomy (minimally-invasive). Patient characteristics, perioperative variables, and short- and long-term outcomes were compared. Primary outcomes included mortality and major adverse cardiac events (MACE). Secondary outcomes were morbidity.Results: A total of 42 MICABG and 54 conventional LIMA-LAD procedures were performed with 95.2% of MICABG procedures performed by two surgeons. MICABG were more often elective (83.3 vs 38.9%, P < .001). STS risk scores predicted equitable mortality and morbidity for MICABG dependent on operative indication. MICABG was associated with fewer pulmonary complications (0.0 vs 11.1%, P = .033), in-hospital events (11.9 vs 37.0%, P = .005), and shorter intensive care unit (34.1 vs 66.0 hours, P = .022) and total length of stay (3.7 vs 6.5 days, P = .002). There were no observed strokes, myocardial infarctions, or reoperations. MICABG patients demonstrated reduced thirty-day mortality (0.0 vs 10.9%, P = .036) and improved Kaplan-Meier 5-year (95.2 vs 77.9%, P = .016) and MACE-free survival (89.2 vs 63.9%, P = .010).Conclusions: Minimally-invasive LIMA-LAD CABG demonstrates improved early postoperative morbidity and a long-term mortality benefit. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial when performed by experienced surgeons in the elective setting. [ABSTRACT FROM AUTHOR]

Background: We sought to identify the independent predictors of blood transfusion requirement in robotic beating-heart patients with totally endoscopic coronary artery bypass (TECAB).Methods: We retrospectively reviewed patients undergoing TECAB with distal anastomotic connectors from July 2013 to May 2017 at our institution. The cohorts were divided into patients who received a blood transfusion (BT group) and patients who did not (non-blood transfusion [NBT] group).Results: Two-hundred seventy-four consecutive patients underwent TECAB, and 47 patients (17%; BT group) received BT. The BT group had a lower preoperative hemoglobin level and a higher rate of preoperative risk profiles and higher society of thoracic surgeons (STS) predicted the risk of mortality. Kaplan Meier analysis showed decreased 1-year survival in the BT group compared with the NBT group (90.9% vs 96.4%; logrank, 0.017). The Youden index identified a preoperative hemoglobin cutoff value of 12.2 g/dL (sensitivity 60.9%, specificity 79.3%) and operative time of 300 minutes (sensitivity 61.7%, specificity 59.0%) for BT requirement. Multivariate logistic regression analysis identified a preoperative hemoglobin <12.2 g/dL (odds ratio, 6.03; 95% confidence interval, 3.01-12.1) and an operative time >300 minutes (odds ratio, 2.15; 95% confidence interval, 1.07-4.33) as independent factors associated with BT requirement.Conclusions: We found that preoperative hemoglobin and operative time were independent predictors of BT requirement during robotic beating-heart TECAB. These data would help to select patients to minimize perioperative BT as well as predict outcomes after this procedure. [ABSTRACT FROM AUTHOR]

Objective: Retrosternal thyroid is the presence of thyroid tissue in the mediastinum either by enlarging of the cervical or by an ectopic mediastinal thyroid. Surgery for a retrosternal thyroid has technical differences than conventional cervical thyroid surgery and has a higher risk of complications. This paper aims to analyze the cases with retrosternal thyroid and to evaluate the outcomes of the surgery. Materials and Methods: Retrospective analysis in terms of age, sex, clinical course, thyroid hormone levels, parathormone (PTH) levels, diagnostic methods, and fine needle aspiration cytology (FNAC) results and complications of 36 cases that underwent surgery was performed. Results: In addition to routine evaluation for thyroid pathology, computerized tomography was used for each patient. Thirty-four surgeries were completed with a cervical incision, one with a sternotomy and one with a thoracotomy. Four patients (11.1%) experienced temporary postoperative hypocalcemia, and one patient had a transient vocal cord immobility. Neither permanent hypocalcemia nor vocal cord paralysis was present in any of the patients postoperatively. Conclusion: Planning surgery as early as possible is suggested to avoid compression symptoms and possible malignancy. Cervical approach is mostly enough for the majority of patients; however, in case of a need of an additional (transthoracic) approach, multidisciplinary planning with thoracic surgeons is proposed. The risk of complications in experienced centers is parallel to cervical thyroidectomy. [ABSTRACT FROM AUTHOR]

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The management of patients with mitral regurgitation (MR) undergoing transcatheter aortic valve replacement (TAVR) is challenging. We sought to investigate the evolution and long-term prognostic impact of residual post-TAVR MR. The severity of MR was assessed at baseline and at 30 days and six months post-TAVR. Left ventricular mass and volumes were assessed by magnetic resonance imaging at two weeks and six months post-TAVR. The study included 970 patients (age, 80.6 ± 6.2 years; female, 53.2%; Society of Thoracic Surgeons score, 5.2 ± 4.6). Moderate-severe MR at baseline improved at 30-day post-TAVR in 60% of cases, and TAVR with the Medtronic CoreValve (OR: 0.44 [0.23–0.86]) was associated with a lower likelihood of improvement. Further MR improvement continued beyond 30 days post-TAVR especially in patients with a significant improvement of left ventricular volume and mass. Stratified by the severity of MR at 30 days post-TAVR, the 5-year cumulative incidence of the composite of cardiovascular mortality or heart failure hospitalization was 37.5%, 40.0%, and 58.2% in patients with none-mild, moderate, and severe MR, respectively (log rank p <.001; adjusted hazard ratio of severe vs. none-mild MR: 4.83 [2.49–9.38]. MR improves in a majority of patients early after TAVR, and its evolution continues thereafter in line with reverse cardiac remodeling. Residual post-TAVR severe MR is associated with adverse long-term outcome. Therefore, intervention to treat severe MR persisting after TAVR should be considered by the heart team. • MR is common in patients undergoing TAVR and improves in a large proportion of them early after the procedure. • TAVR with the Medtronic CoreValve is associated with a lower likelihood of early post-procedural improvement of MR. • The improvement of MR continues further to at least 6 months post-TAVR. • This further improvement is seen in patients who also exhibit effective reverse cardiac remodeling. • Severe MR at 30 days post-TAVR is a strong and independent risk factor for impaired long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Database collects and monitors preoperative, operative, and 30-day outcome data on patients undergoing cardiac surgery, and delivers regular performance feedback reports to key personnel with intent to drive quality improvement. The current feedback approach appears to be ineffective in driving change to minimise Unit performance variation. We sought to determine the acceptability and feasibility of providing structured feedback in addition.Methods: Cardiac surgeons were surveyed to assess their evaluation of the current feedback reports and assist in developing the content of structured feedback. We then assessed acceptability and performance outcomes of control Units receiving current feedback reports via email, versus intervention Units that in addition received structured feedback.Results: Survey respondents assessing the current feedback report agreed that the content is relevant (95%), key performance indicators (KPIs) are useful (85%), and that it would be beneficial to compare surgeons' KPIs (75%). Survey respondents rating method of feedback, requested structured feedback sessions one to two times annually (67%; control Units), and future structured feedback (83%; intervention Units). With combined report and structured feedback, improved performance was noted for an under-performing Unit. Limitations of feedback in driving quality improvement was high performance of Units at baseline, low surgeon participation, and scheduling challenges for structured feedback.Conclusions: In this pilot study, compared to the control method, structured feedback did not significantly improve communication. To maximise quality improvement efforts, a collaborative feedback approach that fosters a climate of continuous performance improvement, is recommended. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Our goal was to report the results of the first consensus paper among international experts in uniportal video-assisted thoracoscopic surgery (UniVATS) lobectomy obtained through a Delphi process, the objective of which was to define and standardize the main procedural steps, optimize its indications and perioperative management and identify elements to assist in future training. METHODS The 40 members of the working group were convened and organized on a voluntary basis by the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). An e-consensus finding exercise using the Delphi method was applied to require 75% agreement for reaching consensus on each question. Repeated iterations of anonymous voting continued for 3 rounds. RESULTS Overall, 31 international experts from 18 countries completed all 3 rounds of questionnaires. Although a technical quorum was not achieved, most of the responders agreed that the maximum size of a UniVATS incision should be ≤4 cm. Agreement was reached on many points outlining the currently accepted definition of a UniVATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions. CONCLUSIONS The UVIG Consensus Report stated that UniVATS offers a valid alternative to standard VATS techniques. Only longer follow-up and randomized controlled studies will predict whether UniVATS represents a valid alternative approach to multiport VATS for major lung resections or whether it should be performed only in selected cases and by selected centres. The next step for the ESTS UVIG is the establishment of a UniVATS section inside the ESTS databases. [ABSTRACT FROM AUTHOR]

Purpose: Image acquisition protocols and reports in patients with pectus excavatum (PEX) differ significantly from routine examinations, and no imaging modality can enable a comprehensive assessment of PEX severity and cardiac impact within a single examination. We therefore attempt to establish recommendations about preoperative imaging in patients with PEX.Method: Chest computed tomography (CT), stress echocardiography (Echo), and cardiac magnetic resonance (CMR) allow the evaluation of specific information regarding structural and functional characteristics of vital importance to assess surgical candidacy and define surgical strategies. We sought to provide a multidisciplinary state of the art document involving thoracic surgeons, radiologists, and cardiologists; to establish recommendations about the variables to be included in the reports of the imaging examinations performed in patients with PEX.Results: We provide recommendations for preoperative image acquisition and analysis, aimed at the assessment of the severity of the chest wall deformity (CT); the site of maximum cardiac compression, extent of increased interventricular dependence, and presence of pericardial effusion (CMR); and the effect of PEX on the functional capacity and exercise-related systolic and/or diastolic function, and tricuspid annulus compression (Echo).Conclusions: This multidisciplinary state of the art document involving thoracic surgeons, radiologists, and cardiologists provides recommendations about preoperative imaging for patients with PEX. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. [ABSTRACT FROM AUTHOR]

Importance: Transcatheter aortic valve replacement (TAVR) indications are expanding, leading to an increasing number of patients with bicuspid aortic stenosis undergoing TAVR. Pivotal randomized trials conducted to obtain US Food and Drug Administration approval excluded bicuspid anatomy.Objective: To compare the outcomes of TAVR with a balloon-expandable valve for bicuspid vs tricuspid aortic stenosis.Design, Setting, and Participants: Registry-based prospective cohort study of patients undergoing TAVR at 552 US centers. Participants were enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) Transcatheter Valve Therapies Registry from June 2015 to November 2018.Exposures: TAVR for bicuspid vs tricuspid aortic stenosis.Main Outcomes and Measures: Primary outcomes were 30-day and 1-year mortality and stroke. Secondary outcomes included procedural complications, valve hemodynamics, and quality of life assessment.Results: Of 81 822 consecutive patients with aortic stenosis (2726 bicuspid; 79 096 tricuspid), 2691 propensity-score matched pairs of bicuspid and tricuspid aortic stenosis were analyzed (median age, 74 years [interquartile range {IQR}, 66-81 years]; 39.1%, women; mean [SD] STS-predicted risk of mortality, 4.9% [4.0%] and 5.1% [4.2%], respectively). All-cause mortality was not significantly different between patients with bicuspid and tricuspid aortic stenosis at 30 days (2.6% vs 2.5%; hazard ratio [HR], 1.04, [95% CI, 0.74-1.47]) and 1 year (10.5% vs 12.0%; HR, 0.90 [95% CI, 0.73-1.10]). The 30-day stroke rate was significantly higher for bicuspid vs tricuspid aortic stenosis (2.5% vs 1.6%; HR, 1.57 [95% CI, 1.06-2.33]). The risk of procedural complications requiring open heart surgery was significantly higher in the bicuspid vs tricuspid cohort (0.9% vs 0.4%, respectively; absolute risk difference [RD], 0.5% [95% CI, 0%-0.9%]). There were no significant differences in valve hemodynamics. There were no significant differences in moderate or severe paravalvular leak at 30 days (2.0% vs 2.4%; absolute RD, 0.3% [95% CI, -1.3% to 0.7%]) and 1 year (3.2% vs 2.5%; absolute RD, 0.7% [95% CI, -1.3% to 2.7%]). At 1 year there was no significant difference in improvement in quality of life between the groups (difference in improvement in the Kansas City Cardiomyopathy Questionnaire overall summary score, -2.4 [95% CI, -5.1 to 0.3]; P = .08).Conclusions and Relevance: In this preliminary, registry-based study of propensity-matched patients who had undergone transcatheter aortic valve replacement for aortic stenosis, patients with bicuspid vs tricuspid aortic stenosis had no significant difference in 30-day or 1-year mortality but had increased 30-day risk for stroke. Because of the potential for selection bias and the absence of a control group treated surgically for bicuspid stenosis, randomized trials are needed to adequately assess the efficacy and safety of transcatheter aortic valve replacement for bicuspid aortic stenosis. [ABSTRACT FROM AUTHOR]

Intraoperative surgical prosthetic heart valve (SHV) choice is a key determinant of successful surgery and positive postoperative outcomes. Currently, many controversies exist around the sizing and labelling of SHVs rendering the comparison of different valves difficult. To explore solutions, an expert Valve Labelling Task Force was jointly initiated by the European Association for Cardio-Thoracic Surgery (EACTS), The Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS). The EACTS–STS–AATS Valve Labelling Task Force, comprising cardiac surgeons, cardiologists, engineers, regulators and representatives from the International Organization for Standardization (ISO) and major valve manufacturers, held its first in-person meeting in February 2018 in Paris, France. This article was derived from the meeting's discussions. The Task Force identified the following areas for improvement and clarification: reporting of physical dimensions and characteristics of SHVs determining and labelling of SHV size, in vivo and in vitro testing and reporting of SHV haemodynamic performance and thrombogenicity. Furthermore, a thorough understanding of the regulatory background and the role of the applicable ISO standards, together with close cooperation between all stakeholders (including regulatory and standard-setting bodies), is necessary to improve the current situation. Cardiac surgeons should be provided with appropriate information to allow for optimal SHV choice. This first article from the EACTS–STS–AATS Valve Labelling Task Force summarizes the background of SHV sizing and labelling and identifies the most important elements where further standardization is necessary. [ABSTRACT FROM AUTHOR]

Background: Perioperative use of allogeneic blood products is associated with higher morbidity, mortality, and hospital costs after cardiac surgery. Blood conservation techniques such as acute normovolemic hemodilution (ANH) report variable success. We hypothesized that large-volume ANH with limited hemodilution would reduce allogeneic blood transfusion compared to the standard practice.Study Design and Methods: Retrospective observational study of cardiac surgery patients at the University of Maryland Medical Center between January 2014 and September 2017. Using the institutional Society of Thoracic Surgeons database 91 autologous and 981 control patients who underwent coronary artery bypass grafting, aortic valve replacement, or both were identified. After propensity matching of 13 preoperative characteristics, 84 autologous and 84 control patients were evaluated. Our primary endpoint was avoidance of blood transfusion during index hospitalization, and secondary endpoints were postoperative bleeding and major adverse outcomes.Results: The median harvest volumes in the ANH and control groups were 1100 mL and 400 mL, respectively. Of the ANH group, 25% received any transfusion versus 45.2% of the control group after propensity score matching (p < 0.006). When controlling for preoperative platelet count, the transfusion rate ratios for ANH were 0.58 (95% confidence interval, 0.39-0.88) for RBCs and 0.63 (0.44-0.89) for non-RBC components, which were both found to be statistically significant. There was no difference found in major adverse events.Conclusion: These results suggest that large-volume ANH is beneficial in reducing both RBC and non-RBC component usage in cardiac surgery. A further prospective validation is warranted. [ABSTRACT FROM AUTHOR]