Purpose: This study explored the sex differences in the outcomes of degenerative mitral valve repair (MVr).

Methods: From 2010 to 2019, 1069 patients who underwent MVr due to degenerative mitral disease at Beijing Anzhen Hospital were analyzed. The average patient follow-up was 5.1 years (interquartile range: 5–7 years). The primary endpoint was overall survival. Secondary endpoints were freedom from reoperation and recurrent mitral regurgitation. A propensity-matched analysis was used to compare the outcomes of males and females.

Results: Females were older, had a higher prevalence of atrial fibrillation and moderate-to-severe tricuspid regurgitation, and had smaller left atrial, left ventricular end-diastolic, and left ventricular end-systolic diameters. Males were more likely to undergo concomitant coronary artery bypass grafting and had longer cardiopulmonary bypass and aortic cross-clamp times. The in-hospital mortality was <1% (10/1,069). After propensity score matching of 331 pairs of patients, most variables were well balanced. Before and after propensity score matching, the long-term survival and freedom from reoperation rates were similar. Males had higher durability after surgery compared with females.

Conclusions: Females were referred to surgery later and had more complications than males. Long-term survival and freedom from reoperation rates were not significantly different between the sexes.

Purpose: Goal-directed perfusion (GDP) refers to individualized goal-directed therapy using comprehensive monitoring and optimizing the delivery of oxygen during cardiopulmonary bypass (CPB). This study aims to determine whether the intraoperative GDP protocol method has better outcomes compared to conventional methods.

Methods: We searched the PubMed, Central, and Scopus databases up to October 12, 2023. We primarily examined the GDP protocol in adult cardiac surgery, using CPB with oxygen delivery index (DO2I) and cardiac index (CI) as the main parameters.

Results: In all, 1128 participants from seven studies were included in our analysis. The results showed significant differences in the duration of intensive care unit (ICU) stays (p = 0.01), with a mean difference of −0.33 (−0.59 to 0.07), and hospital length of stay (LOS) (p = 0.0002), with a mean difference of −0.84 (−1.29 to −0.39). There was also a notable reduction in postoperative complications (p <0.00001), odds ratio (OR) of 0.43 (0.32–0.60). However, there was no significant decrease in mortality rate (p = 0.54), OR of 0.77 (0.34–1.77).

Conclusion: Postoperative acute kidney injury and ICU and hospital LOS are significantly reduced when GDP protocols with indicators of flow management, oxygen delivery index, and CI are used in intraoperative cardiac surgery using CPB.

Esophagogastric junction cancer (EGJC) is a rare malignant disease that occurs in the gastroesophageal transition zone. In recent years, its incidence has been rapidly increasing not only in Western countries but also in East Asia, and it has been attracting the attention of both clinicians and researchers. EGJC has a worse prognosis than gastric cancer (GC) and is characterized by complex lymphatic drainage pathways in the mediastinal and abdominal regions. EGJC was previously treated in the same way as GC or esophageal cancer, but, in recent years, it has been treated as an independent malignant disease, and treatment focusing only on EGJC has been developed. A recent multicenter prospective study revealed the frequency of lymph node metastasis by station and established the optimal extent of lymph node dissection. In perioperative treatment, the combination of multi-drug chemotherapy, radiation therapy, molecular targeted therapy, and immunotherapy is expected to improve the prognosis. In this review, we summarize previous clinical trials and their important evidence on surgical and perioperative treatments for EGJC.

In this review, we summarize the modifications made in the Japanese Classification of Esophageal Cancer 12th edition, identify several issues, and discuss the prospects for the next 13th edition.

Robotic-assisted minimally invasive esophagectomy (RAMIE) has been rapidly spreading worldwide as a novel minimally invasive approach for esophageal cancer. This narrative review aimed to elucidate the current situation and future perspectives of RAMIE for esophageal cancer. References were searched using PubMed and Embase for studies published up to 8 April 2023. Search terms included “esophagectomy” or “esophageal cancer” and “robot” or “robotic” or “robotic-assisted.” There are several different uses for the robot in esophagectomy. Overall complications are equivalent or may be less in RAMIE than in open esophagectomy and conventional (thoracoscopic) minimally invasive esophagectomy. Several meta-analyses demonstrated the possibility of RAMIE in reducing pulmonary complications, although the equivalent incidence was observed in two randomized controlled trials. RAMIE may increase the number of dissected lymph nodes, especially in the left recurrent laryngeal nerve area. Long-term outcomes are comparable between the procedures, although further research is required. Further progress in robotic technology combined with artificial intelligence is expected.

Purpose: We compared the composite outcome of tricuspid valve (TV) reintervention or heart failure (HF) admission in patients who underwent tricuspid valve replacement (TVR) with tissue vs. mechanical valves.

Patients and Methods: The study included 159 patients who underwent TVR from 2009 to 2019. We grouped the patients according to the valve’s type into tissue valve group (n = 139) and mechanical valve group (n = 20).

Results: The mean age of patients was 52.4 ± 12.8 years, and 117 patients were females (73.6%). Hospital mortality occurred in 20 patients (12.6%); all of them were in the tissue valve group. The composite outcome of reintervention and HF readmission occurred in 8 patients with mechanical valves (40%) vs. 24 patients with tissue valves (17.3%), (P = 0.018). Predictors of reintervention and HF admission were female (subdistributional hazard ratio [SHR]: 1.38–34.3, P = 0.019), stroke (SHR: 1.25–8.76, P = 0.016), hypertension (SHR: 1.13–5.36, P = 0.024), and mechanical valves (SHR: 1.6–10.7, P = 0.003). In post hoc analysis, the difference in the composite outcome was derived from the difference in the reintervention rate that was higher in mechanical valves. Survival did not differ significantly between groups (P = 0.12).

Conclusion: Mechanical TVs have a higher rate of composite outcome of reintervention or HF readmission than tissue TVs that are related mainly to higher rate of reintervention.

Purpose: Segmentectomy and mediastinal lymph node dissection (MLND) are becoming standard procedures for small-sized (<2 cm) peripheral non-small cell lung cancer (NSCLC). Although the benefits of the less resected lung are proven, the extent of lymph node dissection remains unchanged.

Methods: We studied 422 patients who underwent lobectomy with MLND (lobe specific or systemic) for small peripheral NSCLC with clinical N0 disease. Patients with middle lobectomy (n = 39) and a consolidation-to-tumor (C/T) ratio ≤0.50 (n = 33) were excluded. We investigated the clinical factors, lymph node metastasis distributions, and lymph node recurrence patterns of 350 patients.

Results: Thirty-five (10.0%) patients had lymph node metastasis; none with C/T ratio <0.75 had lymph node metastasis and lymph node recurrence. None had solitary lymph node metastasis in the outside lobe-specific MLND. Six patients had mediastinal lymph node metastasis at the initial site of recurrence; none had mediastinal lymph node recurrence outside the lobe-specific MLND, except for two patients with S6 primary disease.

Conclusion: NSCLC patients with small peripheral tumors and a C/T ratio <0.75 during segmentectomy may not require MLND. The optimal MLND for patients with a C/T ratio ≥0.75, except for those with S6 primary, may be lobe-specific MLND.

Purpose: Perceval sutureless valves have gained popularity. Whether this implant performs superior to the traditional sutured prosthesis remains unclear. This meta- analysis compared the Perceval implants versus the sutured conventional valves for aortic valve replacement (AVR).

Methods: This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were accessed: PubMed, Google Scholar, Web of Science, Scopus, and EMBASE. All clinical investigations comparing Perceval versus the conventional prostheses for AVR were considered.

Results: The Perceval group demonstrated higher rate of pacemaker implantation (P <0.00001). Aortic cross-clamp (ACC) time (P <0.00001) and cardiopulmonary bypass (CPB) time (P <0.00001) were shorter in the Perceval group. Similarity was found in mean and peak pressure gradient (P = 0.8 and P = 0.2, respectively), mean aortic valve area (P = 0.3), length of intensive care unit (P = 0.4) and hospital stay (P = 0.2), rate of revision (P = 0.11), hemorrhages (P = 0.05), paravalvular leak (P = 0.3), cerebrovascular complication (P = 0.7), and early mortality (P = 0.06).

Conclusion: Given the shorter ACC time and CPB time, Perceval AVR can be an alternative in high-risk patients. The higher rate of pacemaker implantation following Perceval may limit its routine implantation.

Purpose: A prolonged air leak (PAL) is one of the common postoperative complications of pulmonary resection. The aim of this study was to evaluate the efficacy and safety of pleurodesis with sterile talc or OK-432 for postoperative air leak.

Methods: Patients with postoperative air leak who received chemical pleurodesis using sterile talc or OK-432 were retrospectively identified from medical records data. For pleurodesis with either agent, prior assessment and approval by the hospital safety department were carried out for each case, in addition to individual consent.

Results: Between February 2016 and June 2022, 39 patients had PALs and underwent chemical pleurodesis. Among them, 24 patients received pleurodesis with talc (Talc group) and 15 with OK-432 (OK-432 group). The leak resolved after less than two pleurodesis treatments in 22 patients (91.7%) in the Talc group compared with 14 patients (93.3%) in the OK-432 group. Pleurodesis significantly increased white blood cell counts, C-reactive protein concentration, and body temperature in the OK-432 group compared with that in the Talc group (p <0.001, p = 0.003, and p <0.001, respectively).

Conclusions: Pleurodesis with talc may be an effective treatment option for postoperative air leak. Our findings suggest that talc was as effective as OK-432 and resulted in a milder systemic inflammatory response.

Purpose: This study aimed to show the outcomes of isolated tricuspid valve replacement (ITVR) after left-sided valve surgery (LSVS).

Methods: Patients who underwent ITVR after LSVS were divided into bioprosthetic tricuspid valve (BTV) and mechanical tricuspid valve (MTV) groups. Clinical data were collected and analyzed between groups.

Results: 101 patients were divided into BTV (n = 46) and MTV (n = 55) groups. The mean ages of the BTV and MTV groups were 63.4 ± 8.9 and 52.4 ± 7.6 years, respectively (P <0.01). There was no significant difference in 30-day mortality (BTV 10.9% vs. MTV 5.5%), early postoperative complications, and long-term tricuspid valve (TV)-related adverse events between these two groups. New-onset renal insufficiency was an independent risk factor for early mortality. Survival rates in the BTV group were 94.8% ± 3.6%, 86.5% ± 6.5%, and 54.2% ± 17.6% and in the MTV group were 96.0% ± 2.8%, 79.0% ± 7.4%, and 59.4% ± 14.8% at 1, 5, and 10 years, respectively (P = 0.826).

Conclusion: The TV prosthesis selection in ITVR after LSVS seems to not affect 30-day mortality and early postoperative complications. Long-term survival and the occurrence of TV-related events were also comparable between these two groups.

Purpose: The lactate dehydrogenase-to-albumin ratio (LAR) has been reported as a potential prognostic biomarker in various cancers; however, only a few pieces of information have been reported on esophageal cancer. Therefore, this study aimed to evaluate the prognostic significance of preoperative LAR in patients with esophageal cancer.

Methods: This study included 236 patients (193 men and 43 women; mean age of 66 years [range, 41–83 years]) with esophageal cancer who underwent curative surgery between September 2008 and March 2020. A total of 107 patients underwent upfront surgery, and 129 patients received neoadjuvant treatment. Patients were assigned into two groups, high and low LAR, based on preoperative LAR using a cutoff value of 6.2. The clinicopathological and prognostic significance of preoperative LAR was evaluated in univariate and multivariate analyses.

Results: Patients with deep tumors and neoadjuvant treatment were significantly associated with high LAR (p <0.05). The high LAR group showed a significantly poorer prognosis than the low LAR group (p <0.01). The multivariate analysis for the overall survival showed that deep tumors, lymph node metastasis, and high LAR were independent poor prognostic factors (p <0.05).

Conclusion: High LAR was a useful poor prognostic biomarker in patients with esophageal cancer.

Purpose: Tegafur–uracil (UFT) is the standard postoperative adjuvant therapy for stage IB lung adenocarcinoma (LUAD) in Japan. This study aimed to determine whether UFT is effective in stage IB LUAD with and without epidermal growth factor receptor (EGFR) mutations.

Methods: This retrospective study included 169 patients with stage IB LUAD who underwent complete resection at our department between 2010 and 2021. We investigated the clinicopathological and prognostic impact of EGFR mutations as well as the postoperative use of UFT.

Results: EGFR mutation-positive cases tended to show a higher cumulative recurrence rate than EGFR mutation-negative cases (p = 0.081), while overall survival was comparable between the groups (p = 0.238). In the entire cohort, UFT administration was not an independent prognostic factor in the multivariate regression analysis (p = 0.112). According to a stratification analysis, UFT administration was independently associated with favorable overall survival (p = 0.031) in EGFR mutation-negative cases, while it was not associated with recurrence-free survival (p = 0.991) or overall survival (p = 0.398) in EGFR mutation-positive cases.

Conclusion: UFT administration can improve the prognosis of EGFR mutation-negative LUAD but not EGFR mutation-positive LUAD. Thus, clinical trials of adjuvant-targeted therapy for EGFR mutation-positive stage IB LUAD should also be conducted in Japan.

Purpose: This study aimed to elucidate the strategy of an effective Impella support for better clinical outcomes in patients with a postcardiotomy cardiogenic shock (PCCS).

Methods: This single-center retrospective observational study enrolled 31 patients with PCCS undergoing an elective open-heart surgery followed by Impella support between November 2018 and February 2022 for further analysis.

Results: The preoperative Euroscore II and left ventricular (LV) ejection fraction were 9.1 ± 10.4 and 35.7% ± 12.6%, respectively. The in-hospital mortality rate was 51.6% (n = 16). In survivors (n = 15), the mean Impella support time was 6.9 ± 3.5 days. Patients were discharged on the postoperative day 24.9 ± 16.4. Regarding LV remodeling, LV end-diastolic diameter was significantly decreased after Impella support (59.2 ± 6.0 mm vs. 54.4 ± 4.7 mm, p = 0.01, preoperative vs. postoperative). In-hospital mortality rates were comparable with small (CP, n = 6) or large (5.0, n = 25) Impella systems (33.3% [n = 2] vs. 56.0% [n = 14], p = 0.39). However, a lower in-hospital mortality rate was observed in the group with early initiation (i.e., intraoperative) of Impella support (n = 14) than that with delayed Impella initiation (i.e., in the postoperative course) (n = 11) (28.6% [n = 4] vs. 90.9% [n = 10], p = 0.004).

Conclusions: Impella support contributes to LV remodeling in PCCS patients. In-hospital mortality was comparable in different Impella sizes and lower in early Impella initiation.

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

Purpose: This meta-analysis aimed to compare the prognosis of lung transplantation recipients based on donor age.

Methods: A detailed search was performed in PubMed, Embase, Web of Science, and the Cochrane Library for cohort studies on lung transplantation. The prognosis of lung transplant recipients was investigated based on the donor age, with the primary outcomes being 1-year overall survival (OS), 3-year OS, 5-year OS, and 5-year chronic lung allograft dysfunction (CLAD)-free survival.

Results: This meta-analysis included 10 cohort studies. Among the short-term outcomes, the older donor group demonstrated no significant difference from the young donor group in primary graft dysfunction within 72 hours, use of extracorporeal membrane oxygenation, length of ventilator use, and intensive care unit hours. However, a longer hospital stay was associated with the older donor group. In terms of long-term outcomes, no difference was found between the two groups in 1-year OS, 3-year OS, and 5-year OS. Notably, patients with older donors exhibited a superior 5-year CLAD-free survival.

Conclusions: The results of this meta-analysis indicate that older donors are not inferior to younger donors in terms of long-term and short-term recipient outcomes. Lung transplantation using older donors is a potential therapeutic option after rigorous evaluation.

Purpose: Aortic valve neocuspidization (AVNeo) is a relatively recent advancement in surgical AV replacement. Data on its performance beyond the short term are limited. We assessed the mid-term outcomes in patients undergoing AVNeo, focusing on feasibility, perioperative details, and its role in AV pathology treatment.

Methods: Sixty-five consecutive patients underwent AVNeo between December 2016 and February 2018. Clinical data were prospectively collected and retrospectively analyzed. Tricuspid reconstruction with autologous pericardium was performed in all cases. Echocardiographic follow-up was conducted post-discharge, at 6 and 12 months, and annually thereafter.

Results: The mean age was 62.6 ± 18.7 years. AVNeo was feasible in all cases. Concomitant procedures were performed in 43 (66.2%) patients. Mean bypass and cross-clamp times were 119.2 ± 30.3 and 87.1 ± 22.9 minutes, respectively. Postoperative transvalvular hemodynamics was excellent. There was one (1.5%) in-hospital death. Follow-up (mean 66.72 ± 12.77 months) was complete in 58 patients (89.2%). There were no detected valve-related or thromboembolic events. Transvalvular hemodynamic parameters were stable during the observation period: peak pressure gradient at discharge and follow-up was 15.3 ± 4.6 mmHg and 15.01 ± 6.3 mmHg, respectively (ρ = 0.346).

Conclusions: AVNeo demonstrated the feasibility and favorable mid-term outcomes. Studies with longer-term observation are warranted to evaluate its durability.

Purpose: Achieving a secure anastomosis and complete hemostasis is essential for surgically treating type A acute aortic dissection (TAAAD). This study assessed the clinical feasibility of “tailored stand-up collar (TSC)” technique for constructing the distal stump.

Methods: We enrolled 68 patients who underwent ascending aortic repair for TAAAD. Patients were categorized according to the technique for distal stump construction: conventional (C) group using only a felt strip (32 cases); post-aortotomy (P) group, with a Hydrofit-felt strip attached after aortotomy (18 cases), and TSC group, where a Hydrofit-felt strip attached during cooling (18 cases). Pre-operative characteristics, procedural profiles, and post-operative outcomes were evaluated.

Results: The pre-operative characteristics were identical among the groups. The durations of cardiopulmonary bypass, hemostasis, and surgery were significantly shorter in the P and TSC groups. The duration of open distal in the TSC group (21 min) was significantly shorter than the other two groups. Post-operative additional procedures were not required for the TSC group and their post-operative hospital stay was significantly shorter (47.1% of patients were discharged within 2 weeks).

Conclusion: The TSC technique would be practical because of its high reproducibility in terms of ease of use, shorter anastomotic time, and secure hemostasis.

Purpose: We aimed to investigate the prognosis and impact of postoperative acute kidney injury (AKI) in acute Stanford type A aortic dissection (ATAAD) patients, and to analyze the predictors of short- and medium-term survival.

Methods: A total of 192 patients who underwent ATAAD surgery were included between May 2014 and May 2019. Perioperative data of these patients were analyzed. All of the discharged patients were followed up for 2 years.

Results: Postoperative AKI was identified in 43 of 192 patients (22.4%). The two-year survival rate of patients with AKI after discharge was 88.2% and that without AKI was 97.2%.The difference was statistically significant (χ² = 5.355, log-rank P = 0.021). Cox hazards regression showed that age (hazard ratio [HR], 1.070; P = 0.002), cardiopulmonary bypass (CPB) time (HR, 1.026; P = 0.026), postoperative AKI (HR, 3.681; P = 0.003), and red blood cell transfusion (HR, 1.548; P = 0.001) were independent risk factors for the short- and medium-term total mortality of ATAAD patients.

Conclusion: The incidence of postoperative AKI is high in ATAAD, and the mortality of patients with AKI increases significantly within 2 years. Age, CPB time, and red blood cell transfusion were also independent risk factors for short-and medium-term prognoses.

Purpose: This study evaluated the Controlling Nutritional Status (CONUT) score as a prognostic predictor in elderly non-small cell lung cancer (NSCLC) patients with surgical resection.

Methods: Overall, 114 patients over 80 years old undergoing curative resection for NSCLC were retrospectively analyzed. Receiver operating characteristic (ROC) analysis was conducted to evaluate the capacity of immune-inflammatory markers to predict overall survival (OS). Cox-proportional hazards regression analysis was implemented to investigate prognostic markers for OS.

Results: Based on ROC curves, the CONUT score was found to be the most valuable prognostic marker (area under the curve = 0.716). The high CONUT (≥2) group included 54 patients, and the low CONUT (0 or 1) group included 60 patients. The high CONUT group had poorer prognosis rates compared to the low CONUT group with regard to OS (5-year OS: 46.3% vs. 86.0%, p = 0.0006). In the multivariate data analysis, histology, lymphatic invasion, and CONUT score (hazard ratio: 4.23, p = 0.0003) were found to be exclusive and independent prognostic markers for OS.

Conclusion: Preoperatively, the CONUT score can be used as a novel prognostic marker in elderly NSCLC patients. CONUT evaluations can also be used to design nutritional interventions to improve patient outcomes.

The incidence of gastric tube cancers has increased due to improved survival rates in patients after esophagectomy. However, the optimal surgical approach for gastric tube cancer remains controversial. Here, we report the case of a 70-year-old man with advanced gastric cancer arising from a retrosternally placed gastric conduit, 12 years after thoracic esophagectomy for esophageal cancer. Total resection of the gastric conduit was performed with robotic assistance. Although the working space was limited, secure resection was possible. Continuous en bloc mobilization was achieved with neck dissection, and reconstruction was performed via the same retrosternal route using the ileocolon. The patient was discharged on the 14th postoperative day without any adverse events. Robot-assisted surgery can overcome the technical limitations of laparoscopic mediastinal surgery and has advantages such as improved ergonomics, comfort, and elimination of hand tremors, and therefore may be an option for future minimally invasive surgeries.