Background: We present a technique for mitral valve (MV) replacement that preserves the anterior mitral leaflet (AML) using complete chordal-sparing mitral valve replacement (CCS-MVR), which maintains the architecture of the left ventricle. This technique is beneficial for patients with functional, degenerative, and infective MV disease who were unable to undergo MV repair. The objective of this study is to ascertain the most efficacious treatment for MV disease. Furthermore, the study will contribute to international guidelines for this procedure and provide data on its efficacy in treating MV disease.

Methods: We performed MV replacement surgery on 161 patients, maintaining the integrity of the entire subvalvular chordae tendineae apparatus. Of these cases, 92 (57.1%) were degenerative, 58 (36.0%) were functional, 9 (5.6%) were infective, and 2 (1.2%) were rheumatic. Of the 93 patients with complicated MV disease, massive calcification was observed in 59 cases (36.6%) and mitral annular disjunction (MAD) was observed in 25 cases (15.5%) while endocarditis with posterior annular abscess was observed in 9 cases (5.6%). The anterior leaflet is detached from its connection to the annulus along the entire extent from the posterior commissure to the anterior commissure. In cases of excess tissue, a section of the free edge of the translocated leaflet must be removed. This must preserve a small section of the edge and the entire chordae tendineae unit. A CCS-MVR requires 24 to 28 individual sutures in routine cases. The AML was reinserted using 12 to 14 single sutures in this specific order: posterior annulus, posterior mitral leaflet, AML, and prosthetic valve.

Results: The 30-day mortality rate was 8.7%, based on 14 cases. Ten patients, representing 5% of the total, required reoperation after the initial procedure. Out of 140 patients,74 (52.8%) experienced LV reverse remodeling at the six-month follow-up. Female patients exhibited a significantly higher rate of LV reverse remodeling (71% vs. 29%, P<0.001) compared to male patients. Patients with mitral annular calcification and MAD demonstrated significantly higher rates of left ventricular reverse remodeling compared to patients with coronary artery disease (CAD). We can conclude with certainty that male gender, CAD, atrial fibrillation, and preoperative left ventricular end-diastolic volume indexed (LVEDVI) are significant predictors of LV remodeling. We found that the median survival time after CCS-MVR was 39.5 months. The results of the multivariable analysis revealed that patients with MAD had significantly worse survival rates than those without.

Conclusions: For patients presenting with severely calcified posterior mitral annulus, complicated Barlow disease with MAD, or endocarditis involving the posterior annulus, the AML is consolidated with the posterior mitral leaflet to form a neo-annulus. This procedure is safe and effective for a wide range of simple and complex MV pathologies. Its efficacy is unquestionable. It preserves the complete architecture of the left ventricle, avoiding dilatation and promoting reverse remodeling.

Keywords: Mitral valve (MV); mitral valve replacement (MVR); chordal preservation; chordal sparing

Background: Lung cancer has become the second most common cancer and the leading cause of cancer death in the United States. We aim to determine factors associated with newly diagnosed lung cancer at the Emergency Department (ED) and identify specific patient populations eligible for lung cancer diagnostic screening.

Methods: This is a single-center retrospective observational study. We included all patients aged between 50 and 80 years old, who presented to the ED seeking healthcare between January 1, 2019, and December 31, 2023. Patients’ socio-demographics, clinical information, and whether they were eligible for lung cancer screening determined by the United States Preventive Services Task Force (USPSTF) guideline were analyzed and compared between patients who had newly diagnosed lung cancer at ED and those without. Factors associated with newly diagnosed lung cancer patients were determined by multivariable logistic regressions with inverse probability weighting (IPW) to account for observed selection bias of lung cancer screening eligibility.

Results: Out of 75,516 patients in this study, 18,641 (25%) patients had documented smoking histories. Among these, only 8,051 (10.66%) were eligible for lung cancer screening, while 18,348 patients received lung computer tomography (CT). Among all patients whose CTs were performed, 123 individuals were identified as having been newly diagnosed with lung cancer. Multivariable logistic regressions showed that the adjusted odds ratio (AOR) for eligible lung cancer diagnostic screening was 3.07 [95% confidence interval (CI): 2.08–4.53, P<0.001] without IPW and 3.49 (95% CI: 2.24–5.42, P<0.001) with IPW. Other factors associated with newly diagnosed lung cancer in ED were older age, female, and patients who spoke neither English nor Spanish.

Conclusions: To optimize the identification of suitable patients for lung cancer diagnostic screening in the ED, it may be beneficial to modify the eligibility criteria beyond those currently outlined by the USPSTF guidelines. Integrating additional factors such as advanced age, female sex, and a preference for non-English languages could improve the screening’s effectiveness by capturing at-risk populations that might otherwise be overlooked.

Keywords: Lung cancer; screening eligibility; Emergency Department (ED)

Background: Managing malignant pleural effusion (MPE) with pleurodesis is essential for symptom relief and minimizing the need for repeated thoracentesis. Interstitial lung disease (ILD) is one of the most common complications associated with advanced lung cancer. However, the efficacy and safety of pleurodesis for MPE secondary to lung cancer with ILD remains unclear. This study aimed to evaluate the efficacy and safety of pleurodesis in this population.

Methods: This study was a single-center retrospective analysis. The cases of pleurodesis in patients with MPE secondary to lung cancer complicated with ILD at Nippon Medical School Hospital (Tokyo, Japan) between January 2010 and December 2022 were included.

Results: Of the 26 lung cancer patients with ILD who underwent pleurodesis were analyzed. Fourteen patients received talc and 12 patients received minocycline, respectively. Talc was used in 10 out of 14 patients with drug-induced ILD and radiation-induced lung injury (RILI). In contrast, minocycline was used in 10 out of 12 patients with idiopathic interstitial pneumonias (IIPs). One month after pleurodesis, the efficacy for pleural adhesions was 64.3% and 50.0% in the talc and minocycline groups. The presence of a partially expanded lung before pleurodesis was a predictive factor for failure [odds ratio: 7.00, 95% confidence interval (CI): 1.20–40.83, P=0.04]. When excluding the patients presenting partially expanded lung, the efficacy rate was 77.8% and 71.4% in the talc and minocycline groups. One case of grade 5 acute respiratory distress syndrome (ARDS) was observed in each group. All cases developing ARDS had been treated with systemic prednisolone against ILDs presenting ground glass opacity and consolidation within 6 months before pleurodesis.

Conclusions: Pleurodesis is considered to be one of the treatment options against MPE in patients with ILD. However, two cases of ARDS were observed; thus, clinicians should carefully consider the indication of pleurodesis in the patients who had the recent onset of ILD and were treated with systemic prednisolone.

Keywords: Lung cancer; malignant pleural effusion (MPE); pleurodesis; interstitial lung disease (ILD)

Background: Renal function is a crucial factor affecting the prognosis of patients with end-stage heart failure (HF). The differential impacts of heart transplantation and left ventricular assist device (LVAD) implantation on renal function are unclear. Therefore, we compared the perioperative renal function changes in patients who underwent heart transplantation with that of patients who underwent LVAD implantation.

Methods: This study included 77 patients who underwent heart transplantation and 59 patients who underwent LVAD implantation at five hospitals between January 2019 and December 2023. These patients were divided into two groups based on surgery type: heart transplantation or LVAD implantation. The estimated glomerular filtration rates (eGFRs) before surgery and on postoperative days (PODs) 1, 7, and 30 were compared. A subgroup analysis was conducted for patients with preoperative renal dysfunction, and paired-samples t-tests were used to compare renal function changes before and one month after surgery.

Results: Patients in the LVAD group were older (56.4 vs. 44.4 years, P<0.001) and had lower preoperative eGFRs (72.5 vs. 91.3 mL/min/1.73 m², P=0.001) than patients in the heart transplantation group did. On POD 1 and POD 7, the LVAD group continued to have a lower eGFR than the heart transplantation group. The baseline eGFRs were not significantly different (63.3 vs. 60.4 mL/min/1.73 m², P=0.44) in patients with preoperative renal dysfunction (eGFR <90 mL/min/1.73 m²). However, on PODs 1, 7, and 30, the eGFR in the LVAD group was significantly greater than that in the heart transplantation group. By POD 30, renal function in the LVAD group had recovered to near-normal levels (60.4–87.6 mL/min/1.73 m²), whereas in the heart transplantation group, the eGFR remained close to the preoperative level (63.3–63.4 mL/min/1.73 m²). In the LVAD group, the eGFR significantly increased on POD 30, with 84.7% (50/59) of the LVAD patients showing varying degrees of improvement in renal function. In the heart transplantation group, patients’ eGFRs on POD 30 were comparable to their preoperative values, with more than half of them showing a decreased eGFR. Among the patients with preoperative renal dysfunction, 10 without a history of preoperative continuous renal replacement therapy (CRRT) underwent postoperative CRRT in the heart transplantation group; nine of them died within three months of transplantation. In the LVAD group, three patients without preoperative CRRT support required CRRT postoperatively, with one case of early mortality.

Conclusions: For patients with end-stage HF and concurrent renal dysfunction, compared to heart transplantation, LVAD implantation with this new device resulted in significantly improved renal function. With no malfunctions, the device operated in a safe and effective manner and was successfully managed to improve renal function.

Keywords: Left ventricular assist device (LVAD); heart transplantation; renal function; end-stage heart failure (end-stage HF)

Background: Fluorine 18-labeled fibroblast activation protein inhibitor (¹⁸F-FAPI-04) positron emission tomography/computed tomography (PET/CT) has shown promise for the visualization of advanced stage lung cancer. The accuracy of ¹⁸F-FAPI-04 compared with that of fluorine-18 labeled-fluorodeoxyglucose (¹⁸F-FDG) in detecting early lung adenocarcinoma (LUAD) remains unknown. Taking the surgical pathology of pulmonary nodule as the gold standard, the diagnostic performance of stage IA LUAD were compared between ¹⁸F-FAPI-04 PET/CT and ¹⁸F-FDG PET/CT, and the correlation between ¹⁸F-FAPI-04 uptake and pathological characteristics of stage IA LUAD.

Methods: This prospective study from February 2023 to October 2023 analyzed patients with stage IA LUAD who underwent simultaneous examinations with ¹⁸F-FAPI-04 and ¹⁸F-FDG PET/CT. Semi-quantitative parameters such as maximum standardized uptake value (SUVmax), tumor-to-background ratio (TBR), metabolic tumor volume (MTV), total lesion glycolysis (TLG), FAPI avid tumor volume (FTV), and total lesion FAP expression (TLF) were calculated. The two patterns were compared using either a paired Student’s t-test or a Wilcoxon signed-rank test. Immunohistochemical (IHC) staining for detecting fibroblast activating protein (FAP) expression was performed in all resected tumor specimens. Correlation analysis was performed between ¹⁸F-FAPI-04 uptake and pathological features of stage IA LUAD.

Results: A total of 20 patients diagnosed with stage IA LUAD were included in this study. A total of 24 pulmonary nodules were identified in these 20 patients, all of whom were confirmed to have stage IA LUAD through operation and pathology. Of them, 17 nodules were stained by FAP immunohistochemistry. Compared with ¹⁸F-FDG, ¹⁸F-FAPI-04 PET/CT showed a statistically significant increase in SUVmax and TBR for stage IA LUAD, both in the overall and stratified analyses (adenocarcinoma in situ + minimally invasive adenocarcinoma groups vs. invasive adenocarcinoma groups; moderately vs. well-differentiated lesions; stage IA1 vs. IA2+3; P<0.05). The SUVmax of the intense FAP expression group was significantly higher than that of the mild FAP expression group, demonstrating a statistically significant difference (P=0.005). The FAP-IHC score was positively correlated with the SUVmax of ¹⁸F-FAPI-04 (r=0.64, P=0.005).

Conclusions: ¹⁸F-FAPI-04 PET/CT demonstrates higher SUVmax and TBR than ¹⁸F-FDG PET/CT in the detection of stage IA LUAD. It was re-assured that the ¹⁸F-FAPI-04 uptake of stage IA LUAD was positively correlated with the expression of FAP in vitro.

Keywords: Lung adenocarcinoma (LUAD); fibroblast activation protein; fluorine 18-labeled fibroblast activation protein inhibitor (¹⁸F-FAPI-04); ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG); positron emission tomography/computed tomography (PET/CT)

Background: As an increasing number of patients with both lung cancer and coronary artery disease (CAD) are being discovered, doctors face great challenges in treating this group. Off-pump coronary artery bypass grafting (CABG) combined with simultaneous radical surgery for lung cancer has become an option at some institutions. In this study, we aimed to explore postoperative complications, hospitalization duration and expenses, and surgical safety among patients who underwent simultaneous pulmonary resection and off-pump CABG, in order to provide a new treatment approach for lung cancer patients with coronary heart disease (CHD).

Methods: This study collected 85 patients who underwent lung resection and off-pump CABG at Tianjin Chest Hospital from 2020 to 2023. According to different methods of lung surgery, it is divided into two groups: lobectomy combined with off-pump CABG and wedge resection combined with off-pump CABG. These two groups were compared with 78 patients who only received off-pump CABG in terms of hospitalization time and cost, perioperative safety, and surgical complications, in order to evaluate the feasibility of lung resection combined with off-pump CABG.

Results: From the perspective of cardiac function, simultaneous pulmonary resection (lobectomy or wedge resection) and off-pump CABG did not affect postoperative cardiac function compared with off-pump CABG alone [left ventricle (LV): P=0.19; pulmonary artery systolic pressure (PASP): P=0.93; left ventricular ejection fraction (LVEF): P=0.89]. From the perspective of postoperative complications, the combined operation did not increase the incidence of respiratory-related complications (P=0.87) or cardiovascular-related complications (P=0.72) and secondary surgical events (P=0.19), but it did increase the incidence of surgery-related complications (such as chylothorax and air leakage), 15.4%:2.6%, which was manageable. In terms of perioperative safety, intraoperative blood loss during the combined operation was manageable (580 mL:450 mL) and did not significantly prolong the operation time (P>0.05).

Conclusions: Off-pump CABG combined with pulmonary resection is safe during the perioperative period, and the incidence of postoperative complications is manageable, thus reducing overall hospitalization costs. However, combined surgery poses certain technical difficulties and should be performed at experienced institutions.

Keywords: Pulmonary resection; off-pump coronary artery bypass grafting (off-pump CABG); perioperative safety; postoperative complications; hospitalization expenses

Background: Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality worldwide. Bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBV) offers a minimally invasive treatment for severe emphysema. Traditionally performed under general anesthesia (GA), this study evaluates whether BLVR performed under moderate sedation (MS) potentially has less adverse events as compared to ones done under GA.

Methods: This retrospective analysis included 65 patients who underwent BLVR with EBV placement at the University of Florida between January 2020 and June 2022. All procedures were performed under MS. Primary outcomes assessed included the incidence of pneumothorax (PTX), while secondary outcomes comprised valve removal rates, need for revision bronchoscopy, and other procedural complications.

Results: The incidence of PTX was 16.9%, lower than the previously reported rate of 26% in studies combining GA and MS. No major complications or deaths were reported. Procedures were successfully completed in all patients, with valves deployed as planned. Revision bronchoscopy was required in 21.5% of cases.

Conclusions: BLVR under MS is demonstrated to be safe and feasible, with a lower rate of complications compared to GA. These findings suggest that MS may be a preferred sedation method for BLVR, though further research is warranted to confirm these results and explore the long-term outcomes and cost implications

Keywords: Bronchoscopic lung volume reduction (BLVR); moderate sedation (MS); chronic obstructive pulmonary disease (COPD); pneumothorax (PTX)

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide, largely driven by the accumulation of senescent bronchial epithelial cells, which contribute to inflammation and tissue remodeling. This study investigates the therapeutic potential of nuclear factor erythroid 2-related factor 2 (Nrf2) activation in targeting senescence-related changes to alleviate COPD progression.

Methods: Single-cell transcriptome analysis, in vitro COPD cell models, and a COPD mouse model were utilized to examine the effects of Nrf2 activation. Specifically, the study focused on the impact of Nrf2 on senescent ciliated epithelial cells and the associated secretory phenotype. Respiratory function tests and lung pathology assessments were conducted to evaluate the intervention’s efficacy in the mouse model.

Results: The study identified a significant presence of senescent ciliated epithelial cells in COPD patients, contributing to disease progression. Nrf2 activation in vitro reduced senescence markers, enhanced cell proliferation, and decreased inflammatory cytokines. In vivo, Nrf2 activation significantly improved lung function and reduced pathological damage in the COPD mouse model.

Conclusions: The findings underscore the potential of Nrf2 activation as a therapeutic strategy to mitigate COPD progression by modulating the senescence-associated secretory phenotype (SASP). This study suggests that Nrf2 activators could offer a promising approach to improving clinical outcomes for COPD patients.

Keywords: Chronic obstructive pulmonary disease (COPD); nuclear factor erythroid 2-related factor 2 activator (Nrf2 activator); epithelial cell senescence; senescence-related secretory phenotype; single-cell transcriptome sequencing

Background: The endobronchial ultrasound (EBUS) elastography is a diagnostic tool used for measuring the elasticity of intrathoracic lesions. It is still essential for discussions about how accurate elastography is at identifying benign and malignant mediastinal and hilar lymph nodes. The objective of this study was to investigate the diagnostic utility of EBUS elastography and to determine the variables affecting this procedure.

Methods: We conducted a single-center, retrospective study involving patients with suspected lung cancer who underwent EBUS elastography followed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) at Zhejiang Cancer Hospital between October 2021 and March 2023. The pathological results of EBUS-TBNA, validated through a six-month follow-up, served as the gold standard. Each lymph node had its ultrasonic elastography indices recorded, including the elastography grading score, blue color ratio (BCR), blue color score, and short axis diameter. The diagnostic efficacy of elastography was assessed using the receiver operating characteristic (ROC) curve, which differentiated between benign and malignant lymph nodes. To investigate the factors impacting the elastography indices, multivariate logistic regression was used with multiple serological markers, lymph node location, and pathology.

Results: Of the 168 patients, 322 lymph nodes were punctured, with 175 (54.3%) being malignant. The area under the ROC curve (AUC) for the combined index of elastography grading score and short-axis diameter was 0.702 [95% confidence interval (CI): 0.645–0.759]. While the pathology of the lymph nodes was found to influence the BCR, BCR was unable to distinguish between lymph nodes with benign conditions and those with small cell carcinoma.

Conclusions: The use of elastography data alone may be inadequate for diagnosing metastatic lymph nodes. However, elastography can provide supplementary diagnostic information during EBUS-TBNA. Invasive EBUS-TBNA remains recommended as it aids in the identification of malignant lymph nodes when used in conjunction with pathological, radiological, and clinical findings.

Keywords: Endobronchial ultrasound (EBUS); elastography; endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA); lung cancer; mediastinal lymph node metastasis

Background: Positional indications for sublobar resection have been increasingly focused by clinical surgeons while the surgical strategies for cases involving inter-multisegmental veins (IMSVs) remain underreported. We want to further clarify the positional indications for sublobar resection in patients with clinical T1a–bN0 non-small cell lung cancer (NSCLC).

Methods: The clinical data of 686 patients from August 2021 to July 2022 were retrospectively analyzed. In the three-dimensional (3D) reconstruction images, we analyzed the prevalence and drainage patterns of typical IMSVs, specifically focusing on the lateral vein (Vl) in the upper lobes and the branches of the superior segmental vein (V⁶b) in the lower lobes. The potential association between lesion locations and surgical strategy was also analyzed.

Results: The prevalence of Vl, V⁶b2, and V⁶b3 was 58.5% (231/395), 98.3% (286/291), and 25.1% (73/291), respectively. Vl mainly drained into V²a+b (70/110, 63.6%) on the right and into V¹⁺²b+c (72/121, 59.5%) on the left. V⁶b2 and V⁶b3 mainly converged with other branches of the superior segmental vein. Limited resection was more feasible when the 2 cm simulated cutting margin of nodules did not involve IMSVs, or when lesions were located in the outer region. Multivariable logistic regression analyses identified four independent predictors for surgical procedure selection: (I) whether the 2 cm simulated cutting margin involves IMSVs; (II) diameter; (III) consolidation-to-tumour ratio (CTR); and (IV) depth ratio.

Conclusions: IMSVs exhibited high prevalences, with Vl showing diverse drainage patterns, while V⁶b2 and V⁶b3 displayed little variation. Depth ratio and the lesion’s relative location to the IMSVs were identified as longitudinal and transverse positional indications, respectively, for sublobar resection in patients with clinical T1a–bN0 NSCLC.

Keywords: Pulmonary nodule; three-dimensional reconstruction (3D reconstruction); inter-multisegmental vein (IMSV); sublobar resection