<div><h4>Aortic Root Geometry following Composite Valve Graft Implantation - Implications for Future Valve-in-valve Procedures.</h4><i>Werner P, Kuscu BS, Coti I, Puchner S, ... Andreas M, Ehrlich M</i><br /><b>Objectives</b><br />Biological composite valve grafts (CVGs) are being performed more frequently, which increases the need for interventions treating bioprosthetic valve failure. The feasibility of valve-in-valve (ViV) procedures in this population is uncertain. This study aimed to assess changes in aortic root geometry and coronary height following CVG implantation to better understand future interventions.<br /><b>Methods</b><br />We retrospectively identified 64 patients following bioprosthetic CVG replacement with pre- and postoperative computed tomography angiography. Root assessment was conducted as in preprocedural transcatheter aortic valve evaluation using a virtual valve simulation.<br /><b>Results</b><br />In 64 patients (age 67.6±9.3 years, 76.6% male) the preoperative coronary height was 14.3±6.8 mm for the left coronary artery (LCA) and 17.9±5.9 mm for the right coronary artery (RCA), which significantly decreased after CVG implantation, with 8.7±4.4 mm for the LCA and 11.3±4.4 mm for the RCA (p<0.001). The virtual valve-to-coronary distances measured 4.0±1.3 mm (LCA) and 4.6±1.4 mm (RCA). Overall, 59.4% (n=38) of patients with bio-CVGs would have been at risk for coronary obstruction, 29.7% (n=19) for LCA, 10.9% (n=7) for RCA and 18.8% (n=12) for combined LCA and RCA.<br /><b>Conclusions</b><br />Coronary height significantly decreased following CVG implantation. The majority of patients after bio-CVG were at a potential risk for coronary obstruction in future ViV procedures. Further studies are needed to identify the best possible technique for coronary reimplantation and other measures to diminish the risk for future coronary obstruction in this population.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 30 May 2023; epub ahead of print</small></div>

<div><h4>Longer Hospitalizations, More Complications, and Greater Readmissions for Patients with Comorbid Psychiatric Disorders Undergoing Pulmonary Lobectomy.</h4><i>Kim AT, Ding L, Lee HB, Ashbrook MJ, ... Harano T, Kim AW</i><br /><b>Objective</b><br />To examine the impact of comorbid psychiatric disorders on postoperative outcomes in pulmonary lobectomy patients.<br /><b>Methods</b><br />A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2016-2018 was performed. Lung cancer patients with and without psychiatric comorbidities who underwent pulmonary lobectomy were collated and analyzed (International Classification of Diseases, 10<sup>th</sup> Revision, Clinical Modification (ICD-10-CM) Mental, Behavioral and Neurodevelopmental disorders (F01-99; PSYD)). The association of PSYD with complications, length of stay (LOS), and readmissions was assessed using a multivariable regression analysis. Additional subgroup analyses were performed.<br /><b>Results</b><br />41,691 patients met inclusion criteria. 27.84% (11,605) of the patients had at least one PSYD. PSYD was associated with a significantly increased risk of postoperative complications (RR 1.041; 95% CI: 1.015-1.068; p=0.0018), pulmonary complications (RR 1.125; 95% CI: 1.08-1.171; p<0.0001), longer LOS (PSYD Mean - 6.79 days; Non-PSYD Mean - 5.68 days; p<0.0001), higher 30-day readmission rate (9.2% vs. 7.9%; p<0.0001), and 90-day readmission rate (15.4% vs. 12.9%; p<0.007). Among PSYD, those with cognitive disorders and psychotic disorders (e.g. schizophrenia) appear to have highest rates and risks of post-operative morbidity and in-hospital mortality.<br /><b>Conclusion</b><br />Lung cancer patients with comorbid psychiatric disorders undergoing lobectomy experience worse postoperative outcomes with longer hospitalization, increased rates of overall and pulmonary complications, and greater readmissions suggesting potential opportunities for improved psychiatric care during the perioperative period.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 26 May 2023; epub ahead of print</small></div>

<div><h4>Valve-Sparing Root Replacement vs. Composite Valve Graft Root Replacement: Analysis of >1500 Patients from Two Aortic Centers.</h4><i>Levine D, Patel P, Wang C, Pan C, ... Chen E, Takayama H</i><br /><b>Objectives</b><br />The long-term outcomes comparing valve-sparing root replacement (VSRR), composite valve graft with bioprosthesis (b-CVG) and mechanical prosthesis (m-CVG) have yet to be explored. We investigated long-term survival and reintervention rates after undergoing one of three major aortic root replacements in both tricuspid and bicuspid aortic valve (AV) patients.<br /><b>Methods</b><br />A total of 1507 patients underwent VSRR (n=700), b-CVG (n=703), or m-CVG (n=104) between 2004-2021 from two aortic centers, excluding those with dissection, endocarditis, stenosis, or prior AV surgery. Endpoints included mortality over time and cumulative incidence of AV/proximal aorta reintervention. Multivariable Cox Regression compared adjusted 12-year survival. Fine and Gray competing risk regression compared risk and cumulative incidence of reintervention. Propensity score matched (PSM) subgroup analysis balanced the two major groups (b-CVG and VSRR), and landmark analysis isolated outcomes beginning four years postoperatively.<br /><b>Results</b><br />On multivariable analysis, both b-CVG (HR 1.91, p=0.001) and m-CVG (HR 2.62, p=0.005) had increased 12-year mortality risk vs VSRR. After PSM, VSRR displayed improved 12-year survival vs b-CVG (87.9% vs 78.8%, p=0.033). Adjusted 12-year reintervention risk in b-CVG or m-CVG vs VSRR patients was similar [(b-CVG sHR 1.49, p=0.170); (m-CVG sHR 0.28, p=0.110)], with cumulative incidence 7% in VSRR, 17% in b-CVG, and 2% in m-CVG (p=0.420). Landmark analysis at four years showed increased incidence of late reintervention in b-CVG vs VSRR (p=0.008).<br /><b>Conclusions</b><br />VSRR, m-CVG, and b-CVG have excellent 12-year survival, with VSRR associated with better survival. All three groups have low incidence of reintervention, with VSRR showing decreased late post-operative need for reintervention compared to b-CVG.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 26 May 2023; epub ahead of print</small></div>

<div><h4>Surgical outcomes of aortic valve repair for specific aortic valve cusp characteristics; retraction, calcification and fenestration.</h4><i>Mathari SE, Boulidam N, de Heer F, de Kerchove L, ... Kluin J, Aortic Valve Research Network Investigators</i><br /><b>Objectives</b><br />We investigated the predictive value of aortic valve cusp retraction, calcification and fenestration for aortic valvuloplasty feasibility.<br /><b>Methods</b><br />Multicenter data was collected for 2082 patients who underwent surgical aortic valvuloplasty or aortic valve replacement. The study population had retraction, calcification or fenestration in at least one aortic valve cusp. Controls had normal or prolapsed cusps.<br /><b>Results</b><br />All cusp characteristics demonstrated significantly increased OR\'s for switch to valve replacement. This effect was strongest for cusp retraction, followed by calcification and fenestration (OR = 25.14, p=<.001; OR = 13.50, p=<.001; OR 12.32, p=<.001). Calcification and retraction displayed increased odds for developing grade 4 aortic regurgitation compared to grade 0 or 1 combined on average over time (OR = 6.67, p=<.001; OR = 4.13, p=.038). Patients with cusp retraction showed increased risk for reintervention at 1- and 2-years follow-up after aortic valvuloplasty (HR = 5.66, p=<.001; HR = 3.22, p=.007). Cusp fenestration was the only group showing neither an increased risk of postoperative severe aortic regurgitation (p=0.57) or early reintervention (p=0.88) compared to the control group.<br /><b>Conclusions</b><br />Aortic valve cusp retraction, calcification and fenestration were all related to increased rates of switch to valve replacement. Calcification and retraction were associated with recurrence of severe aortic regurgitation. Retraction was related to early reintervention. Fenestration was neither associated with recurrence of severe aortic regurgitation or reintervention. This indicates that surgeons are well able to distinguish aortic valve repair candidates in patients with cusp fenestration.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 25 May 2023; epub ahead of print</small></div>

<div><h4>The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery.</h4><i>Vanstraelen S, Ali B, Bains MS, Shahzad F, ... Jones DR, Rocco G</i><br /><b>Objective</b><br />Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular free flaps (MVFFs) have increased, particularly for defects where PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.<br /><b>Methods</b><br />We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. Endpoints were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.<br /><b>Results</b><br />In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n=28; PF, n=105). The median (interquartile range) covered defect size was 172 cm<sup>2</sup> (100-216 cm<sup>2</sup>) for MVFF patients versus 109 cm<sup>2</sup> (75-148 cm<sup>2</sup>) for PF patients (p=0.004). The rate of R0 resection was high in both groups (MVFF, 93% [n=26]; PF, 86% [n=90]; p=0.5). The rate of local recurrence was 4% in MVFF patients (n=1) versus 12% in PF patients (n=13, p=0.3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37 [95% CI, 0.39-5.14]; p=0.6). Operative time >400 min was associated with 30-day complications (odds ratio, 3.22 [95% CI, 1.10-9.93]; p=0.033).<br /><b>Conclusions</b><br />Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 24 May 2023; epub ahead of print</small></div>

<div><h4>Routine Chest Radiography After Thoracostomy Tube Removal and During Postoperative Follow-Up is Not Necessary After Lung Resection.</h4><i>Heidel JS, Miller J, Donovan E, Handa R, ... Salfity H, Starnes SL</i><br /><b>Objectives</b><br />The need for routine chest radiography (CXR) following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine CXR in these patients.<br /><b>Methods</b><br />Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007-2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine CXRs post-chest tube removal and at first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of CXRs obtained routinely versus for symptoms. Characteristics and outcomes were compared using Student\'s t-test and chi-squared analyses.<br /><b>Results</b><br />A total of 322 patients met inclusion criteria. Ninety-three underwent a routine same-day post-pull CXR and 229 did not. Thirty-three (14.4%) in the non-routine CXR cohort had imaging for symptoms, of which eight cases (24.2%) resulted in management changes. Only 3.2% of routine post-pull CXR resulted in management changes versus 3.5% of unplanned CXRs with no adverse outcomes (p=0.905). At outpatient postoperative follow-up, 146 patients received a routine CXR; none resulted in a change in management. Of the 176 that did not have a planned CXR at follow-up, 12 patients (6.8%) underwent a CXR for symptoms. Two of these patients required readmission and chest tube re-insertion.<br /><b>Conclusion</b><br />Reserving imaging for patients with symptoms at post-chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 24 May 2023; epub ahead of print</small></div>

<div><h4>Long-term Outcomes of Tricuspid Valve Intervention During Stage 2 Palliation in Patients with a Single Right Ventricle.</h4><i>Smerling JL, Goldstone AB, Bacha EA, Liberman L</i><br /><b>Objectives</b><br />In single ventricle patients with a systemic right ventricle, tricuspid valve regurgitation increases the risk of adverse outcomes, and tricuspid valve intervention at the time of staged palliation further increases that risk in the post-operative period. Long-term outcomes of valve intervention in patients with significant regurgitation during stage 2 palliation, however, have not been established. The purpose of this study is to evaluate long-term outcomes after tricuspid valve intervention during stage 2 palliation in patients with RV dominant circulation in a multicenter study.<br /><b>Methods</b><br />The study was performed using the SVR and SVR II datasets. Survival analysis was performed to describe the association between valve regurgitation, intervention, and long-term survival. Cox proportional-hazards modeling was used to estimate the longitudinal association of tricuspid intervention and transplant-free survival.<br /><b>Results</b><br />Patients with tricuspid regurgitation at either stage 1 or 2 had worse transplant-free survival (HR 1.61, 95% CI 1.12-2.32; HR 2.3, 95% CI 1.39-3.82). Those with regurgitation who underwent concomitant valve intervention at stage 2 were significantly more likely to die or undergo heart transplantation compared to those with regurgitation who did not (HR 2.93, CI 2.16-3.99). Patients with tricuspid regurgitation at the time of Fontan had favorable outcomes regardless of valve intervention.<br /><b>Conclusions</b><br />The risks associated with tricuspid regurgitation in single ventricle patients do not appear to be mitigated by valve intervention at the time of stage 2 palliation. Patients who underwent valve intervention for tricuspid regurgitation at stage 2 had significantly worse survival compared with patients with tricuspid regurgitation who did not.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 22 May 2023; epub ahead of print</small></div>

<div><h4>Center Case Volume is Associated with Society of Thoracic Surgeons-Defined Failure to Rescue in Cardiac Surgery.</h4><i>Strobel RJ, Young AM, Rotar EP, Kaplan EF, ... Teman NR, Investigators for the Virginia Cardiac Services Quality Initiative</i><br /><b>Objective</b><br />Our understanding of the impact of a center\'s case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR.<br /><b>Methods</b><br />Patients undergoing an STS index operation in a regional collaborative (2011-2021) were included. After excluding patients with missing STS predicted risk of mortality, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared to all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year.<br /><b>Results</b><br />A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th-percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly higher center-level major complication rates, but lower mortality and FTR rates (all p-values < 0.01). Observed to expected FTR was significantly associated with case volume (p = 0.040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (OR 0.87 per quartile, CI 0.80 - 0.95, p = 0.001).<br /><b>Conclusions</b><br />Increasing center case volume is significantly associated with improved failure to rescue rates. Assessment of low volume centers\' FTR performance represents an opportunity for quality improvement.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 May 2023; epub ahead of print</small></div>

<div><h4>Mitochondrial Transplantation Preserves Myocardial Function and Viability in Pediatric and Neonatal Donation After Circulatory Death Pig Hearts.</h4><i>Alemany VS, Nomoto R, Saeed MY, Celik A, ... Del Nido PJ, McCully JD</i><br /><b>Objective</b><br />Mitochondrial transplantation has been shown to preserve myocardial function and viability in porcine DCD adult hearts. Herein, we investigate the efficacy of mitochondrial transplantation for the preservation of myocardial function and viability in neonatal and pediatric porcine DCD heart donation.<br /><b>Methods</b><br />Circulatory death was induced in neonatal and pediatric Yorkshire pigs by cessation of mechanical ventilation. Hearts underwent 20 or 36 min. of warm ischemia time (WIT), 10 min. of cold cardioplegic arrest and then were harvested for ex-situ heart perfusion (ESHP). Following 15 min. of ESHP, hearts received either vehicle (VEH) or vehicle containing isolated autologous mitochondria (MITO). A sham non-ischemic group (SHAM) did not undergo WIT mimicking donation after brain death (DBD) heart procurement. Hearts underwent 2 hr. each of unloaded and loaded ESHP perfusion.<br /><b>Results</b><br />Following 4 hr. ESHP perfusion, LVDP, dP/dt max, and fractional shortening were significantly decreased (P< 0.001) in DCD hearts receiving VEH compared to Sham hearts. In contrast, DCD hearts receiving MITO exhibited significantly preserved LVDP, dP/dt max, and fractional shortening (P<0.001 each vs VEH, not significant vs SHAM). Infarct size was significantly decreased in DCD hearts receiving MITO as compared to VEH (P< 0.001). Pediatric DCD hearts subjected to extended WIT demonstrated significantly preserved fractional shortening and significantly decreased infarct size with MITO (P< 0.01 each vs VEH).<br /><b>Conclusions</b><br />Mitochondrial transplantation in neonatal and pediatric pig DCD heart donation significantly enhances the preservation of myocardial function and viability and mitigates against damage secondary to extended WIT.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 May 2023; epub ahead of print</small></div>

<div><h4>The Importance of Timing in Post-Cardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: a Descriptive Multicenter Observational Study.</h4><i>Mariani S, Wang IW, van Bussel BCT, Heuts S, ... Lorusso R, PELS-1 Investigators</i><br /><b>Objectives</b><br />Post-cardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intra-operatively or post-operatively based on indications, settings, patient profile and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patients´ characteristics, in-hospital and long-term survival between intra-operative and post-operative ECMO.<br /><b>Methods</b><br />The retrospective, multicentre, observational Post-cardiotomy Extracorporeal Life Support (PELS-1) Study includes adults requiring ECMO due to post-cardiotomy shock between 2000 and 2020. We compare patients who received ECMO in the operating theatre (intra-operative) with those in the intensive care unit (post-operative) on in-hospital and post-discharge outcomes.<br /><b>Results</b><br />We studied 2003 patients [women:41.1%; median age:65 (IQR:55.0-72.0) years]. Intra-operative (n=1287), compared to post-operative (n=716), ECMO patients had worse pre-operative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for post-operative ECMO initiation, with cannulation occurring after (median) 1 day (IQR:1-3 days). Compared to intra-operative application, post-operative ECMO showed more complications, cardiac reoperations (intra-operative:19.7%; post-operative: 24.8%, p=0.011), percutaneous coronary interventions (intra-operative:1.8%; post-operative: 3.6%, p=0.026), and had higher in-hospital mortality (intra-operative:57.5%; post-operative: 64.5%, p=0.002). Among hospital survivors, ECMO duration was shorter after intra-operative ECMO (median:104, IQR:67.8-164.2 hours) compared to post-operative ECMO (median:139.7, IQR:95.8-192 hours, p<0.001), while post-discharge long-term survival was similar between the two groups (p=0.86).<br /><b>Conclusions</b><br />Intra-operative and post-operative ECMO implantations are associated with different patients\' characteristics and outcomes, with higher complications and in-hospital mortality after post-operative ECMO. Strategies to identify the optimal location and timing of post-cardiotomy ECMO in relation to specific patient\'s characteristics are warranted to optimize in-hospital outcomes.<br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 16 May 2023; epub ahead of print</small></div>

<div><h4>Meta-Analysis of Phase-Specific Survival After Transcatheter versus Surgical Aortic Valve Replacement from Randomized Control Trials.</h4><i>Yokoyama Y, Shimoda T, Sloan B, Takagi H, Fukuhara S, Kuno T</i><br /><b>Objective</b><br />Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical aortic valve replacement (SAVR) for severe symptomatic aortic stenosis, although phase specific survival and cause of death are implicated following these procedures. Herein, we conducted a phase-specific meta-analysis to compare outcomes after TAVR versus SAVR.<br /><b>Methods</b><br />A systematic search of databases was performed from inception through December 2022 to identify randomized controlled trials (RCTs) that compared outcomes of TAVR and SAVR. For each trial, the hazard ratio (HR) with 95% confidence interval (CI) of outcomes of interest was extracted for the following each specific phase: the very short-term (0-1 years after the procedure), short-term (1-2 years), and mid-term (2-5 years). Phase-specific HRs were separately pooled using the random-effects model.<br /><b>Results</b><br />Our analysis included 8 RCTs which enrolled a total of 8,885 patients with a mean age of 79 years. The survival after TAVR compared with SAVR was higher in the very short-term periods (HR [95% CI] =0.85 [0.74-0.98]; P=0.02) but similar in the short-term periods. In contrast, lower survival was observed in the TAVR group compared with the SAVR group in the mid-term periods (HR [95% CI] =1.15 [1.03-1.29]; P=0.02). Similar temporal trends favoring SAVR in the mid-term were present for cardiovascular mortality and rehospitalization rates. In contrast, the rates of aortic valve reinterventions and permanent pacemaker implantations were initially higher in the TAVR group, although SAVR\'s superiority eventually disappeared in the mid-term.<br /><b>Conclusions</b><br />Our analysis demonstrated phase specific outcomes following TAVR and SAVR.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 04 May 2023; epub ahead of print</small></div>

<div><h4>Hybrid Palliation Versus Non-Hybrid Management for a Multi-Institutional Cohort of Infants with Critical Left Heart Obstruction.</h4><i>Argo MB, Barron DJ, Bondarenko I, Eckhauser A, ... Haw MP, McCrindle BW</i><br /><b>Objective</b><br />To compare patient characteristics and overall survival for infants with critical left heart obstruction (CLHO) after hybrid palliation (bilateral pulmonary artery banding ± ductal stenting) versus non-hybrid management (e.g., Norwood, primary transplantation, biventricular repair, transcatheter/surgical aortic valvotomy).<br /><b>Methods</b><br />From 2005-2019, 1,045 infants in the Congenital Heart Surgeons\' Society CLHO cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent non-hybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the two groups was adjusted by applying balancing scores to nonparametric estimates.<br /><b>Results</b><br />Compared to the non-hybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, non-cardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all p-values <0.03). Unadjusted 12-year survival after hybrid palliation and non-hybrid management, was 55% versus 69% respectively. After matching, 12-year survival after hybrid palliation versus non-hybrid management was 58% versus 63%, respectively (p=0.37). Among matched infants born weighing <2.5kg, 2-year survival after hybrid palliation versus non-hybrid management was 37% versus 51%, respectively (p=0.22).<br /><b>Conclusions</b><br />Infants born with CLHO who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo non-hybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus non-hybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower birth weight infants.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 03 May 2023; epub ahead of print</small></div>

<div><h4>Prognostic value of KRAS G12C mutation in lung adenocarcinoma stratified by stages and radiological features.</h4><i>Cao H, Ma Z, Li Y, Zhang Y, Chen H</i><br /><b>Objectives</b><br />The role of KRAS G12C is of particular interest given the promising clinical activity of KRAS G12C-specific inhibitors. This study comprehensively investigated the clinicopathological characteristics and prognostic value of KRAS G12C mutation in patients with surgically resected lung adenocarcinoma.<br /><b>Methods</b><br />Data were collected on 3828 patients with completely resected primary lung adenocarcinomas who underwent KRAS mutation analysis between 2008 and 2020. The association between KRAS G12C and clinicopathologic characteristics, molecular profiles, recurrence patterns, and postoperative outcome were explored.<br /><b>Results</b><br />275 patients (7.2%) were confirmed to harbor a KRAS mutation, of whom 83 (30.2%) had the G12C subtype. KRAS G12C was more frequent in males, former/current smokers, radiologic solid nodules, invasive mucinous adenocarcinoma, and solid predominant tumors. KRAS-G12C tumors had more lympho-vascular invasion and higher programmed death-ligand 1 expression than KRAS wild-type tumors. TP53 (36.8%), STK11 (26.3%), and RET (18.4%) mutations were the three most frequent in the KRAS G12C group. Logistic regression analysis showed patients with KRAS G12C mutation were prone to experience early recurrence and locoregional recurrence. KRAS G12C mutation was found to be significantly associated with poor survival after propensity score matching. Stratified analysis showed that the KRAS G12C was an independent prognostic factor in stage I tumors and part-solid lesions, respectively.<br /><b>Conclusions</b><br />The KRAS G12C mutation had a significant prognostic value in stage I lung adenocarcinomas as well as in part-solid tumors. Furthermore, it exhibited a potentially aggressive phenotype associated with early and locoregional recurrence. These findings might be relevant as better KRAS treatments are developed for clinical application.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 02 May 2023; epub ahead of print</small></div>

<div><h4>Assessing the impact of publications: A bibliometric analysis of the top-cited articles from The Journal of Thoracic and Cardiovascular Surgery.</h4><i>Castro-Varela A, Schaff HV</i><br /><b>Objective</b><br />After 90 years, The Journal of Thoracic and Cardiovascular Surgery (JTCVS) remains one of the most influential and widely read journals in our specialty. This study analyzes the characteristics of its top-cited articles over the past 6 decades.<br /><b>Methods</b><br />Using Elsevier\'s Scopus database, we identified all papers published in JTCVS since 1959. After exclusion of expert consensus guidelines, articles were grouped by decade and ranked by the total number of citations. We included the field-weighted citation impact (FWCI) when available. We analyzed the characteristics of the 10 most cited documents overall and per decade.<br /><b>Results</b><br />The Journal published a total of 32,335 papers, of which 14,052 were published between 2010 and 2021. The order of the top-cited articles differs when ranked by citations versus FWCI. During the last 6 decades, the 10 most cited articles per decade have a mean number of 604 citations (range, 240-1670) and a mean FWCI of 13.1 (range, 4.3-24.7). There is no overlap in positions when articles are ranked by citations versus FWCI. The majority of the 60 top 10 cited articles over the past 6 decades were presented at a major meeting (n = 38, 63%), most commonly the Annual Meeting of the American Association for Thoracic Surgery. Topics in adult cardiac surgery and general thoracic surgery predominated among the most-cited papers, which originated most often from the United States followed by Japan, Canada, France, England, and Germany.<br /><b>Conclusions</b><br />JTCVS continues to provide a global platform to share impactful knowledge related to surgery for thoracic diseases. The use of citations to determine an article\'s impact has limitations and nontraditional metrics may prove to be an excellent complementary tool for more equitable evaluations.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 May 2023; 165:1901-1916</small></div>

<div><h4>Variation in survival in patients with Coronavirus Disease 2019 supported with extracorporeal membrane oxygenation: A multi-institutional analysis of 594 consecutive patients with Coronavirus Disease 2019 supported with extracorporeal membrane oxygenation at 49 hospitals within 21 states.</h4><i>Jacobs JP, Stammers AH, St Louis JD, Tesdahl EA, ... Badhwar V, Weinstein S</i><br /><b>Objectives</b><br />We reviewed 594 consecutive patients with Coronavirus Disease 2019 supported with extracorporeal membrane oxygenation at 49 hospitals within 21 states and examined patient characteristics, treatments, and variation in outcomes over the course of the pandemic.<br /><b>Methods</b><br />A multi-institutional database was used to assess all patients with Coronavirus Disease 2019 cannulated for extracorporeal membrane oxygenation between March 17, 2020, and December 20, 2021, inclusive, and separated from ECMO on or prior to January 14, 2022. Descriptive analysis was stratified by 4 time categories: group A = March 2020 to June 2020, group B = July 2020 to December 2020, group C = January 2021 to June 2021, group D = July 2021 to December 2021. A Bayesian mixed-effects logistic regression was used to assess continuous trends in survival where time was operationalized as the number of days between each patient\'s cannulation and that of the first patient in March 2020, controlling for multiple variables and risk factors.<br /><b>Results</b><br />At hospital discharge, of 594 patients, 221 survived (37.2%) and 373 died. Throughout the study, median age [interquartile range] declined (group A = 51.0 [41.0-60.0] years, group D = 39.0 [32.0-48.0] years, P < .001); median days between Coronavirus Disease 2019 diagnosis and intubation increased (group A = 4.0 [1.0-8.5], group D = 9.0 [5.0-14.5], P < .001); and use of medications (glucocorticoids, interleukin-6 blockers, antivirals, antimalarials) and convalescent plasma fluctuated significantly (all P < .05). Estimated odds of survival varied over the study period with a decline between April 1, 2020, and November 21, 2020 (odds ratio, 0.39, 95% credible interval, 0.18-0.87, probability of reduction in survival = 95.7%), improvement between November 21, 2020, and May 17, 2021 (odds ratio, 1.85, 95% credible interval, 0.86-4.09, probability of improvement = 93.4%), and decline between May 17, 2021, and December 1, 2021 (odds ratio, 0.49, 95% credible interval, 0.19-1.44, probability of decrease = 92.1%).<br /><b>Conclusions</b><br />Survival for patients with Coronavirus Disease 2019 supported with extracorporeal membrane oxygenation has fluctuated during the stages of the pandemic. Minimizing variability by adherence to best practices may refine the optimal use of extracorporeal membrane oxygenation in a pandemic response.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 May 2023; 165:1837-1848</small></div>

<div><h4>Surgical Management of Non-small-cell Lung Cancer with Limited Metastatic Disease Involving Only the Brain.</h4><i>Kumar A, Kumar S, Potter AL, Raman V, ... Lanuti M, Jeffrey Yang CF</i><br /><b>Objective</b><br />The optimal primary site treatment modality for non-small-cell lung cancer (NSCLC) with brain oligometastases is not well-established. This study sought to evaluate long-term survival of patients with NSCLC with isolated brain metastases undergoing multimodal therapy with or without thoracic surgery.<br /><b>Methods</b><br />Patients with cT1-3, N0-1, M1b-c NSCLC with synchronous limited metastatic disease involving only the brain treated with brain stereotactic radiosurgery (SRS) or neurosurgical resection in the National Cancer Database (2010-2017) were included. Long-term overall survival of patients who underwent multimodal therapy including thoracic surgery (\"Thoracic Surgery\") versus systemic therapy with or without radiation to the lung (\"No Thoracic Surgery\") was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching.<br /><b>Results</b><br />Of the 1,240 patients with NSCLC with brain-only metastases who received brain SRS or neurosurgery and met study inclusion criteria, 270 (21.8%) received primary site resection. The Thoracic Surgery group had improved overall survival compared to the No Thoracic Surgery group in Kaplan-Meier analysis (p<0.001) and after multivariable-adjusted Cox proportional hazards modeling (p<0.001). In a propensity score-matched analysis of 175 patients each in the Thoracic Surgery and No Thoracic Surgery groups, matching on 13 common prognostic variables, thoracic surgery was associated with better survival (p=0.012).<br /><b>Conclusions</b><br />In this national analysis, patients with cT1-3, N0-1, M1b-c NSCLC with isolated limited brain metastases had better overall survival after multimodal therapy including thoracic surgery compared to systemic therapy without surgery. Multimodal thoracic treatment including surgery can be considered for carefully selected patients with NSCLC and limited brain metastases.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Apr 2023; epub ahead of print</small></div>

<div><h4>ELSO Center of Excellence Recognition Associated with Improved Failure to Rescue after Cardiac Arrest.</h4><i>Strobel RJ, Money D, Young A, Wisniewski A, ... Yarboro LT, Teman NR</i><br /><b>Objective</b><br />The influence of Extracorporeal Life Support Organization (ELSO) center of excellence recognition (CoE) on failure to rescue (FTR) after cardiac surgery is unknown. We hypothesized that ELSO CoE would be associated with improved FTR.<br /><b>Methods</b><br />Patients undergoing a Society of Thoracic Surgeons (STS) index operation in a regional collaborative (2011-2021) were included. Patients were stratified by whether their operation was performed at an ELSO CoE. Hierarchical logistic regression analyzed the association between ELSO CoE recognition and FTR.<br /><b>Results</b><br />A total of 43,641 patients were included across 17 centers. In total, 807 developed cardiac arrest with 444 (55%) experiencing failure to rescue after cardiac arrest. Three centers received ELSO CoE recognition, and accounted for 4,238 patients (9.71%). Prior to adjustment, operative mortality was equivalent between ELSO CoE and non-ELSO CoE centers (2.08% vs. 2.36%, p =0.25), as was the rate of any complication (34.5% vs. 33.8%, p = 0.35) and cardiac arrest (1.49% vs. 1.89%, p = 0.07). After adjustment, patients undergoing surgery at an ELSO CoE center were observed to have 44% decreased odds of FTR after cardiac arrest, relative to patients at non-ELSO CoE centers (OR 0.56 CI 0.316-0.993. p = 0.047).<br /><b>Conclusions</b><br />ELSO CoE is associated with improved FTR following cardiac arrest for patients undergoing cardiac surgery. These findings highlight the important role that comprehensive quality programs serve in improving peri-operative outcomes in cardiac surgery.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Apr 2023; epub ahead of print</small></div>

<div><h4>Long-Term Durability of Valve Sparing Root Replacement in Patients with and without Connective Tissue Disease.</h4><i>Ram E, Lau C, Dimagli A, Chu NQ, ... Gaudino M, Girardi LN</i><br /><b>Objective</b><br />The goal of this study was to evaluate the long-term outcomes of valve-sparing root replacement (VSRR) in patients with connective tissue disease (CTD) and compare them to patients without CTD who underwent VSRR for root aneurysm.<br /><b>Methods</b><br />Of 487 patients, 380 (78%) did not have CTD and 107 (22%) had CTD; 97 (91%) with Marfan syndrome, 8 (7%) with Loeys-Dietz syndrome and 2 (2%) with Vascular Ehlers-Danlos syndrome. Operative and long-term outcomes were compared.<br /><b>Results</b><br />The CTD group was younger (36±14 vs. 53±12, p<0.001), had more females (41% vs. 10%, p<0.001) and had less hypertension (28% vs. 78%, p<0.001) and bicuspid aortic valve (8% vs. 28%, p<0.001). Other baseline characteristics did not differ between the groups. Overall operative mortality was nill (p=1.000); the incidence of major postoperative complications was 1.2% (0.9% vs. 1.3%, p=1.000) and did not differ between groups. Residual mild aortic insufficiency (AI) was more frequent in the CTD group (9.3% vs. 1.3%, p<0.001) with no difference in moderate or greater AI. Ten-year survival was 97.3% (97.2% vs.97.4%, log-rank p=0.801). Of the 15 patients with residual AI, 1 had none, 11 remained mild, 2 had moderate and one had severe AI on follow-up. Ten-year freedom from moderate/severe AI was 89.6% (HR 1.05, 95%CI 0.8-1.37; p=0.750) and 10-year freedom from valve reoperation was 94.9% (HR 1.21, 95%CI 0.43-3.39; p=0.717).<br /><b>Conclusion</b><br />The operative outcomes as well as long-term durability of VSRR is excellent in patients with or without CTD. Valve function and durability are not affected by CTD.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Apr 2023; epub ahead of print</small></div>

<div><h4>Reoperation Following Transcatheter Aortic Valve Replacement: Insights From 10-Year Experience.</h4><i>Fukuhara S, Kim KM, Yang B, Romano M, ... Patel HJ, Deeb GM</i><br /><b>Objective</b><br />Transcatheter aortic valve replacement (TAVR) has demonstrated a dramatic growth in the past decade. This study aims to investigate implications of post-TAVR reoperation from our 10-year experience.<br /><b>Methods</b><br />Between 2011 and 2022, 66 post-TAVR patients underwent a reoperation, consisting of 42 (63.6%) patients with native TAVR and 24 (36.4%) patients with valve-in-valve TAVR (VIV-TAVR) after surgical aortic valve replacement (SAVR).<br /><b>Results</b><br />The aggregate proportion of patients belonging to the low/intermediate-risk group at the time of TAVR exceeded that of the high/extreme-risk cohort in 2021. The native TAVR group received a larger TAVR valve, whereas more frequent low-risk status at the time of TAVR than the VIV-TAVR group. Concurrent procedures were highly common during reoperation and isolated SAVR represented only 18.2% of the entire cohort. The native TAVR group demonstrated significantly higher TAVR-explant difficulty index score (2.0 vs. 1.0 points, p <0.001) and operative mortality (14.2% vs. 0%; p=0.079) compared to the VIV-TAVR group. The 8-year cumulative incidence of reoperation was 1.9% and 14.1% (subdistribution hazard ratio [SHR] 8.0, 95% confidence interval [CI] 4.1-15.9, p<0.001) in the native and VIV-TAVR group, respectively. Furthermore, cumulative incidence of valve reintervention, combining reoperations and redo TAVRs, was 3.3% and 19.0% (SHR 6.2, 95% CI 3.6-10.9, p<0.001).<br /><b>Conclusion</b><br />Low-/intermediate-risk patients are emerging as the predominant group necessitating reoperations. Native TAVR was associated with post-implant lower reintervention rates, albeit with higher reoperative technical difficulty and mortality. Conversely, VIV-TAVR was associated with higher reintervention, but demonstrated lower technical difficulty and mortality for reoperation.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Apr 2023; epub ahead of print</small></div>

<div><h4>Prognostic Utility of a Novel Risk Prediction Model of One-Year Mortality in Patients Surviving to Discharge Following Surgery for Congenital or Acquired Heart Disease.</h4><i>Sengupta A, Gauvreau K, Kohlsaat K, Lee JM, ... Del Nido PJ, Nathan M</i><br /><b>Objective</b><br />We sought to develop a novel risk prediction model of one-year mortality following congenital heart surgery that accounts for clinical, anatomic, echocardiographic, and socioeconomic factors.<br /><b>Methods</b><br />This was a single-center, retrospective review of consecutive index operations for congenital or acquired heart disease, from 01/2011-01/2021, among patients with known survival status at one year following discharge from the index hospitalization. The primary outcome was post-discharge mortality at one year. Variables of interest included age, prematurity, non-cardiac anomalies or syndromes, the Childhood Opportunity Index, primary procedure, major adverse postoperative complications, and the Residual Lesion Score. Logistic regression was used to develop a weighted risk score for the primary outcome. Internal validation using a bootstrap-resampling approach was performed.<br /><b>Results</b><br />Of 10,412 consecutive operations for congenital/acquired heart disease, 8,808 (84.6%) met entry criteria, including survival to discharge. There were 190 (2.2%) deaths at one-year post-discharge. A weighted risk score was formulated based on the variables in the final risk prediction model, which included all aforementioned factors of interest. This model had a C-statistic of 0.82 (95% CI 0.80-0.85). The median risk score was 6 (IQR 4-8) points. Patients were categorized as low (score 0-5), medium (score 6-10), high (score 11-15), or very high (score 16-20) risk. The expected probability of mortality was 0.4±0.2%, 2.0±1.1%, 10.1±5.0%, and 36.6±9.6% for low, medium, high, and very high risk patients, respectively.<br /><b>Conclusions</b><br />A risk prediction model of one-year mortality may guide prognostication and follow-up of patients following discharge after surgery for congenital or acquired heart disease.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Apr 2023; epub ahead of print</small></div>

<div><h4>Social Vulnerability is Associated with Increased Post-Operative Morbidity following Esophagectomy.</h4><i>Stuart CM, Dyas AR, Byers S, Velopulos C, ... McCarter MD, Meguid RA</i><br /><b>Objectives</b><br />The effect of a patient\'s Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy.<br /><b>Methods</b><br />This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016-2022. Patients were grouped into low SVI (<75%ile) and high SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the two groups. Multivariable logistic regression was used to control for covariates.<br /><b>Results</b><br />Of 149 esophagectomy patients identified, 27 (18.1%) were in the high SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% versus 4.9%, p=0.029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a post-operative complication (66.7% versus 36.9%, p=0.005), and had higher rates of postoperative pneumonia (25.9% versus 6.6%, p=0.007), jejunal feeding tube complications (14.8% versus 3.3%, p=0.036), and unplanned ICU readmission (29.6% versus 12.3%, p=0.037). Additionally, patients with high SVI had a longer postoperative hospital length of stay (13 versus 10 days, p=0.017). There were no differences in mortality rates. These findings persisted on multivariable analysis.<br /><b>Conclusions</b><br />Patients with high SVI have higher rates of postoperative morbidity following esophagectomy. The effect SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 27 Apr 2023; epub ahead of print</small></div>

<div><h4>Neochordal Goldilocks: Analyzing the Biomechanics of Neochord Length on Papillary Muscle Forces Suggests Higher Tolerance to Shorter Neochordae.</h4><i>Park MH, van Kampen A, Zhu Y, Melnitchouk S, ... Borger MA, Woo YJ</i><br /><b>Objective</b><br />Estimating neochord lengths during mitral valve (MV) repair is challenging, as approximation must be performed largely based on intuition and surgical experience. Little data exist on quantifying the effects of neochord length misestimation. We aimed to evaluate the impact of neochord length on papillary muscle (PM) forces and MV hemodynamics, which is especially pertinent as increased forces have been linked to aberrant MV biomechanics.<br /><b>Methods</b><br />Porcine MVs (n=8) were mounted in an ex vivo heart simulator, and PMs were fixed to high resolution strain gauges, while hemodynamic data were recorded. We used an adjustable system to modulate neochord lengths. Optimal length was qualitatively verified by a single experienced operator, and neochordae were randomly lengthened or shortened in 1 mm increments up to ±5 mm from the optimal length.<br /><b>Results</b><br />Optimal length neochordae resulted in the lowest peak composite PM forces (6.94±0.29 N), significantly different from all lengths >±1 mm. Both longer and shorter neochordae increased forces linearly according to difference from optimal length. Both peak PM forces and MR scaled more aggressively for longer versus shorter neochordae by factors of 1.6 and 6.9, respectively.<br /><b>Conclusions</b><br />Leveraging precision ex vivo heart simulation, we found that millimeter-level neochord length differences can result in significant differences in PM forces and MR, thereby altering valvular biomechanics. Differences in lengthened versus shortened neochordae scaling of forces and MR may indicate different levels of biomechanical tolerance towards longer and shorter neochordae. Our findings highlight the need for more thorough biomechanical understanding of neochordal MV repair.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 26 Apr 2023; epub ahead of print</small></div>

<div><h4>Disparities in early-stage lung cancer outcomes at minority serving hospitals compared to non-minority serving hospitals.</h4><i>Deboever N, Correa A, Feldman H, Mathur U, ... Antonoff MB, Rajaram R</i><br /><b>Objectives</b><br />Disparities in cancer care are omnipresent and originate from a multilevel set of barriers. Our objectives were (1) to describe the likelihood of undergoing surgery for early-stage non-small cell lung cancer (NSCLC) at minority-serving hospitals (MSH), and (2) evaluate the association of race/ethnicity with resection based on MSH status.<br /><b>Methods</b><br />A retrospective study using the National Cancer Database (2008-2016) was conducted including patients with clinical stage I NSCLC. MSH were defined as hospitals in the top decile of providing care to Hispanic or African American (AA) patients. The primary outcome evaluated was receipt of definitive surgery at MSH vs non-MSH. Outcomes related to race/ethnicity stratified by hospital type were also investigated.<br /><b>Results</b><br />142,580 patients were identified from 1192 hospitals (120 MSH and 1072 non-MSH). Most patients (85%, 121,240) were non-Hispanic White (NHW), followed by AA (9%, 12,772), and Hispanic (3%, 3,749). MSH cared for 7.4% (10,491) of the patients included. In adjusted analyses, patients treated at MSH were resected less often than those at non-MSH (odds ratio = 0.87, 95% confidence interval: 0.76-1.00, p=0.0495). AA patients were less likely to receive surgery in the overall analysis (p<0.01), and at MSH specifically (p<0.01), compared to NHW. Hispanic patients had similar rates of resection in the overall analysis (p=0.11); however, at MSH, they underwent surgery more often compared to NHW (p=0.02). Resected patients at MSH had similar OS (median: 91.7 months, 95% CI: 86.6 to 96.8) compared to those resected at non-MSH (median: 85.7 months, 95% CI: 84.5 to 86.8).<br /><b>Conclusions</b><br />Patients with early-stage NSCLC underwent resection less often at MSH compared to non-MSH. Disparities related to underutilization of surgery for AA patients continue to persist, regardless of hospital type.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 26 Apr 2023; epub ahead of print</small></div>

<div><h4>Surgical Ablation of Atrial Fibrillation is Associated with Improved Survival Compared to Appendage Obliteration Alone: An Analysis of 100,000 Medicare Beneficiaries.</h4><i>Mehaffey JH, Hayanga JWA, Wei L, Mascio C, Rankin JS, Badhwar V</i><br /><b>Objective</b><br />Societal guidelines support the concomitant surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery. Recent evidence has highlighted the stroke reduction of left atrial appendage obliteration (LAAO) with or without SA in similar populations. To inform clinical decision-making, we evaluated real-world outcomes of patients with AF undergoing cardiac surgery by comparing no AF management vs. LAAO alone vs. SA+LAAO.<br /><b>Methods</b><br />Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries aged 65 and older with a diagnosis of AF undergoing CABG and/or Mitral/Aortic/Tricuspid valve repair or replacement between January 2018 and December 2020. Diagnosis-related group and International Classification of Diseases 10th revision procedure codes were used to define variables. Risk adjustment was performed with regression analysis using inverse probability weighting of propensity scores and Cox Proportional Hazards models. Subgroup analyses stratified patients by primary operation and paroxysmal or persistent AF.<br /><b>Results</b><br />A total of 103,382 patients with preoperative AF were stratified by SA+LAAO (10,437; 10.1%), LAAO alone (12,901; 12.5%), or no AF management (80,044; 77.4%). Patients with persistent AF (21,076; 20.4%) received the highest proportion of SA+LAAO (4,661 19.4%) and LAAO alone (3,724; 15.4 %) vs. no AF management (15,688; 65.2%). Similarly, patients undergoing open atrial operations (Mitral/Tricuspid; 17,204; 16.6%) had a higher proportions of AF treatment (SA+LAAO 5,267 30.6%; LAAO alone 4,259 24.8%; no AF management 7,678 44.6%). After robust risk-adjustment, SA+LAAO was independently associated with reduced 3-year mortality compared to no AF treatment (HR 0.68, p < 0.001), and to LAAO alone (HR 0.90, p < 0.001). Compared to no AF treatment, readmissions for embolic stroke were lower with both SA+LAAO (HR 0.77, p = 0.009) and LAAO alone (HR 0.73, p<0.001). Reduction in 3-year composite mortality or stroke following SA+LAAO was superior to LAA alone (HR 0.90, p=0.035).<br /><b>Conclusions</b><br />In Medicare beneficiaries with AF undergoing cardiac surgery, the surgical management of AF was associated with lower three-year mortality and readmission for stroke, with SA + LAAO being associated with higher survival compared to LAAO alone.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 25 Apr 2023; epub ahead of print</small></div>

<div><h4>Statewide Data on Surgical Ablation for Atrial Fibrillation: The Data Provide a Path Forward.</h4><i>Ad N, Kang JK, Chinedozi ID, Salenger R, ... Holmes SD, MCSQI Collaborative</i><br /><b>Objective</b><br />Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multiple societal guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used.<br /><b>Methods</b><br />Adult, first-time, nonemergent, patients with preoperative AF between 2014 and 2022 excluding stand-alone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N=4,320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ<sup>2</sup> analyses. Hospital-level Spearman correlations compared hospital volume to proportion of AF patients treated with SA.<br /><b>Results</b><br />Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage=27.8, P<0.001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (r<sub>s</sub>=0.19, P=0.603) with a rate of SA below the state average for academic centers. Of cases with SA (n=1,582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ<sup>2</sup>=392.3, P<0.001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ<sup>2</sup>=219.0, P<0.001) such that radiofrequency energy was more likely to be used in non-mitral procedures.<br /><b>Conclusions</b><br />These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision-making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 24 Apr 2023; epub ahead of print</small></div>

<div><h4>Bicuspid Aortopathy does NOT Require Earlier Surgical Intervention.</h4><i>Zafar MA, Wu J, Vinholo TF, Li Y, ... Rizzo JA, Elefteriades JA</i><br /><b>Objectives</b><br />Guidelines for surgical correction of ascending thoracic aortic aneurysm (ATAA) in bicuspid aortic valve (BAV) patients have oscillated back and forth over the years. In this study, we outline the natural history of the ascending aorta in BAV and TAV (trileaflet aortic valve) ATAA patients followed over time, to ascertain if their behavior differs, and to determine if a different threshold for intervention is required.<br /><b>Methods</b><br />Aortic diameters and long-term complications (adverse aortic events; AAE) of 2428 patients (554 BAV and 1874 TAV) with ATAA prior to operative repair were reviewed. Growth rates, yearly complication rates, event-free survival (Kaplan-Meier), and risk of complications as a function of aortic size (regression analyses) were calculated. Long-term follow-up and precise cause of death granularity was achieved via a comprehensive six-pronged approach.<br /><b>Results</b><br />Aortic growth rate in BAV- vs. TAV-ATAA patients was 0.20 and 0.17 cm/year, respectively (p=0.009), with the rate increasing with increasing aortic size. Yearly AAE rates increased with ATAA size and were lower for BAV patients. The relative risk of AAE exhibited an exponential increase with aortic diameter. BAV patients had a lower all-cause and ascending aorta specific AAE hazard. Age-adjusted 10-year event free survival was significantly better for BAV patients, and BAV emerged as a protective factor against type A dissection, rupture, and ascending aortic death.<br /><b>Conclusion</b><br />The threshold for surgical repair of ascending aneurysm with BAV should not differ from that of TAV. Prophylactic surgery should be considered at 5.0cm for TAV (and BAV) patients at expert centers.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Apr 2023; epub ahead of print</small></div>

<div><h4>Use of the Inspiris Valve in the Native Right Ventricular Outflow Tract is Associated with Early Prosthetic Regurgitation.</h4><i>Nguyen SN, Vinogradsky AV, Sevensky R, Crystal MA, Bacha EA, Goldstone AB</i><br /><b>Objective</b><br />The Inspiris Resilia prosthesis (Edwards Lifesciences, Irvine, CA) has been increasingly used in the pulmonic position with limited performance data. We sought to investigate its durability as a surgical pulmonary valve replacement (PVR).<br /><b>Methods</b><br />We retrospectively reviewed patients who underwent PVR or conduit replacement with an Inspiris or non-Inspiris valve/conduit from 2018-2022. The primary endpoint was freedom from a composite of at least moderate pulmonary regurgitation (PR), pulmonary stenosis (PS), or valve/conduit reintervention. Secondary endpoints were individual components of the composite outcome. To account for baseline differences, propensity matching identified 70 patient pairs.<br /><b>Results</b><br />A total of 227 patients (median age: 19.3 years [IQR, 11.8-34.4]) underwent PVR or conduit replacement (Inspiris: n=120 [52.9%], non-Inspiris: n=107 [47.1%]). Median follow-up was 26.6 months [IQR, 12.4-41.1]. Among matched patients, 2-year freedom from valve failure was lower in the Inspiris group (53.5%±9.3% vs. 78.5%±5.9%, p=0.03), as was freedom from at least moderate PR (54.2%±9.6% vs. 86.4%±4.9%, p<0.01). There was no difference in 2-year freedom from at least moderate PS (p=0.61) or reintervention (p=0.92). Inspiris durability was poorer when implanted in the native right ventricular outflow tract compared to as a conduit, with 18-month freedom from valve failure of 59.0%±9.5% vs. 85.9%±9.5% (p=0.03).<br /><b>Conclusions</b><br />Early durability of the Inspiris valve is poor when implanted in the native right ventricular outflow tract; its unique design may be incompatible with the compliant pulmonary root. Modified implantation techniques or alternative prostheses should be considered.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Apr 2023; epub ahead of print</small></div>

<div><h4>Lung transplantation for COVID-19 respiratory failure in the United States: Outcomes 1 year posttransplant and the impact of preoperative ECMO support.</h4><i>Bermudez C, Bermudez F, Courtwright A, Richards T, ... Usman A, Crespo MM</i><br /><b>Objective</b><br />Patients with end-stage respiratory failure after severe COVID-19 infection may benefit from lung transplant; however, data on transplant outcomes and the impact of prolonged circulatory support prior to transplant in these patients is limited.<br /><b>Methods</b><br />We assessed survival, postoperative complications, and the impact of pretransplant extracorporeal membrane oxygenation (ECMO) in patients undergoing lung transplant in the United States from August 2020 through March 2022 using records validated by United Network for Organ Sharing (UNOS) experts and extracted from the UNOS database.<br /><b>Results</b><br />In 305 patients with COVID-related respiratory failure and validated data, survival for up to 1 year posttransplant did not differ between 188 patients with COVID-related acute respiratory distress syndrome and 117 patients with post-COVID pulmonary fibrosis (p=0.8). Pretransplant ECMO support (median 66 days) was required in 191 patients (63%), and veno-venous ECMO was used in 91.2% of patients. One-, 6- and 12-month survival was not significantly different between patients requiring ECMO and patients without ECMO (95.8% vs 99.1%, 93.1% vs 96.4%, 84.8% vs 90.9%, p=0.2) Additionally, 1-year survival was similar in recipients requiring ECMO for COVID-19 lung failure and recipients requiring ECMO for non-COVID restrictive lung failure (84.8% vs. 78.0%, p=0.1).<br /><b>Conclusions</b><br />These findings suggest that lung transplant in patients with COVID-19 respiratory failure yields acceptable 1-year outcomes. Despite an often more complex postoperative course, prolonged ECMO pretransplant in well-selected patients was associated with adequate clinical and functional status.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 20 Apr 2023; epub ahead of print</small></div>

<div><h4>Long-term Outcomes of Tetralogy of Fallot Repair: A 30-year experience with 960 patients.</h4><i>Ishigami S, Ye XT, Buratto E, Ivanov Y, ... Brizard CP, Konstantinov IE</i><br /><b>Objective</b><br />This study is to evaluate the long-term results of TOF repair and assess the risk factors for adverse outcomes.<br /><b>Methods</b><br />This retrospective study involved 960 patients who underwent trans-atrial trans-pulmonary TOF repair between 1990 and 2020.<br /><b>Results</b><br />Trans-annular patch (TAP) was placed in 722 patients and pulmonary valve preservation (PVP) was achieved in 233 patients. The median age at TOF repair was 9.4 (IQR, 6.2-14.2) months. The median follow-up duration was 10.6 (IQR, 5.4-16.3) years. There were 8 early deaths (0.8%) and 20 late deaths (2.1%). Genetic syndrome and pulmonary valve annulus Z score < -3 were risk factors for mortality. The survival rate was 97.7 % [95% CI: 96.4-98.5] and 94.5% [95% CI: 90.9-96.7] at 10 and 30 years, respectively. Freedom from any reoperation was 86.4% [95% CI: 83.6-88.7.] and 65.4% [95% CI:59.8-70.4] at 10 and 20 years. Post-operative right ventricular outflow tract (RVOT) peak gradient ≥ 25mmHg correlated with reoperation. Propensity score matched analysis demonstrated that freedom from pulmonary valve replacement (PVR) at 15 years was higher in patient with PVP compared to those with TAP (98.2% vs 78.4%, p = 0.004). Freedom form reoperation for RVOT obstruction at 15 years was lower in PVP group compared to TAP group (p = 0.006).<br /><b>Conclusions</b><br />The long-term outcomes of TOF repair are excellent. A post-operative RVOT peak gradient less than 25 mmHg appears to be optimal to prevent reoperation. If pulmonary valve size is suitable, PVP reduced the risk of PVR, yet increased reoperation rate for RVOT obstruction.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 20 Apr 2023; epub ahead of print</small></div>

<div><h4>Reintervention after valve sparing aortic root replacement: a comprehensive analysis of 781 David V procedures.</h4><i>Singh S, Levine D, Patel P, Norton E, ... Chen EP, Takayama H</i><br /><b>Objective</b><br />Studies of reintervention after VSRR are limited by sample size and failure to evaluate all types of reinterventions, including distal aorta and transcatheter interventions. In this report, reintervention after VSRR using a large patient cohort was comprehensively analyzed.<br /><b>Methods</b><br />In a series involving two academic aortic centers, 781 consecutive patients from 2005-2020 undergoing David V VSRR for aortic aneurysm (91%) or dissection (9%) were included. Median age was 50 years and 23% had a bicuspid aortic valve (BAV). Median follow-up was 7.0 years. Open or transcatheter reintervention on the aortic valve (AV), proximal, or distal thoracic aorta were identified. Cumulative incidence was calculated, and sub-distribution hazard models identified factors associated with reintervention. Time-dependent incidence of reintervention was plotted using risk-hazard functions.<br /><b>Results</b><br />Sixty-eight reinterventions (57 open, 11 transcatheter) were performed. Reinterventions were divided by indication into degenerative AV (n=26, including 1 TAVR), endocarditis (n=11), proximal aorta (n=8), and distal aorta (n=23, including 10 TEVARs). Risk of reintervention for endocarditis peaked 1-3 years after VSRR while other indications had stable, low rate of occurrence throughout the follow-up period. The cumulative incidence of reintervention was 12.5% while the cumulative incidence of AV reintervention was 7.0% at 10 years, and was associated with residual postoperative AI. In-hospital mortality after reintervention was 3%.<br /><b>Conclusions</b><br />Reintervention rates after VSRR are relatively low in long-term follow-up and can be performed with acceptable operative risk. The majority of reinterventions are performed for indications other than AV degeneration with the timing of reintervention varying by the specific clinical indication.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>The Impact of Reoperative Surgery on Aortic Root Replacement in the United States.</h4><i>Ogami T, Serna-Gallegos D, Arnaoutakis GJ, Chu D, ... Grimm JC, Sultan I</i><br /><b>Objective</b><br />Reoperative sternotomy (RS) is associated with poor outcomes after cardiac surgery. We aimed to investigate the impact of RS on the outcomes after aortic root replacement (ARR).<br /><b>Methods</b><br />All patients who underwent ARR from January 2011 through June 2020 were identified using the Society of Thoracic Surgery Adult Cardiac Surgery Database. We compared outcomes between patients who underwent first-time ARR (FT ARR group) to those with a history of sternotomy undergoing RS ARR (RS ARR group) using propensity-score matching. Subgroup analysis was performed among the RS ARR group.<br /><b>Results</b><br />A total of 56,447 patients underwent ARR. Among them, 14,935 (26.5%) underwent RS ARR. The annual incidence of RS ARR increased from 542 in 2011 to 2,300 in 2019. Aneurysm and dissection were more frequently observed in the FT ARR group while infective endocarditis was more common in the RS ARR group. Propensity-score matching yielded 9,568 pairs in each group. Cardiopulmonary bypass time was longer in the RS ARR group (215 min vs. 179 min, SMD = .43). Operative mortality was higher in the RS ARR group (10.8% vs. 6.2%, SMD = .17). In the subgroup analysis, logistic regression demonstrated that individual patient repetition of (second or more resternotomy) surgery and annual institutional volume of ARR were independently associated with operative mortality.<br /><b>Conclusions</b><br />The incidence of RS ARR might have increased over time. Reoperative sternotomy is a significant risk factor for morbidity and mortality in ARR. Referral to high-volume aortic centers should be considered in patients undergoing RS ARR.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Revascularization of Coronary Circulation in Pulmonary Atresia with Intact Ventricular Septum and Right Ventricular-Dependent Coronary Circulation.</h4><i>Najm HK, Costello JP, Karamlou T, Amdani S, Suntharos P, Marino B</i><br /><b>Objective</b><br />Pulmonary atresia with intact ventricular septum and right ventricular-dependent coronary circulation presents unique challenges for survival due to the precarious coronary circulation. We propose revascularization of the right ventricle with aortic oxygenated blood via a graft from aorta to hypoplastic tricuspid valve to stabilize the newborn until the next procedure.<br /><b>Methods</b><br />This full-term, 4.4 kg, 3-week-old neonate with pulmonary atresia with intact ventricular septum and right ventricular-dependent coronary circulation was maintained on prostaglandin infusion following birth. She developed significant myocardial ischemia as her pulmonary vascular resistance fell. Heart transplant listing was pursued. To stabilize the precarious coronary circulation, a graft from aorta to tricuspid valve was planned in addition to a modified Blalock-Taussig-Thomas shunt. On cardiopulmonary bypass, a 5 mm saphenous vein homograft was routed through the right atrial wall and anastomosed directly to the 5 mm tricuspid valve annulus. After weaning from bypass successfully, the patient was electively placed on left ventricular assist device support with PediMag.<br /><b>Results</b><br />PediMag support was weaned off on postoperative day #3. At 6 months of age, the patient underwent elective bidirectional cavo-pulmonary shunt, complete excision of the tricuspid valve, and upsizing of her aorta-to-tricuspid valve graft with 6 mm ringed Gore-Tex. She was removed from the transplant list at 9 months of age.<br /><b>Conclusions</b><br />The use of an aorta-to-tricuspid valve graft in this high-risk anatomy avoids coronary ischemia and the need for long-term assist device support while either awaiting transplantation or the next stage in single ventricle palliation.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>A Novel Ex Vivo Tracheobronchomalacia Model for Airway Stent Testing and In Vivo Model Refinement.</h4><i>Mondal A, Visner GA, Kaza AK, Dupont PE</i><br /><b>Objectives</b><br />We sought to develop an ex vivo trachea model capable of producing mild, moderate and severe tracheobronchomalacia (TBM) for optimizing airway stent design. We also aimed to determine the amount of cartilage resection required for achieving different TBM grades that can be utilized in animal models.<br /><b>Methods</b><br />We developed an ex vivo trachea test system which enabled video-based measurement of internal cross-sectional area as intratracheal pressure was cyclically varied for peak negative pressures of 20-80cm H<sub>2</sub>O. Fresh ovine tracheas were induced with TBM by single midanterior incision (n=4), midanterior circumferential cartilage resection of 25% (n=4) and 50% per cartilage ring (n=4) along a ∼3cm length. Intact tracheas (n=4) were used as control. All experimental tracheas were mounted and experimentally evaluated. In addition, helical stents of two different pitches (6mm and 12mm) and wire diameters (0.52mm and 0.6mm) were tested in tracheas with 25% (n=3) and 50% (n=3) circumferentially resected cartilage rings. The percentage collapse in tracheal cross-sectional area was calculated from the recorded video contours for each experiment.<br /><b>Results</b><br />Ex vivo tracheas compromised by single incision, 25% and 50% circumferential cartilage resection produce tracheal collapse corresponding to clinical grades of mild, moderate and severe TBM, respectively. A single anterior cartilage incision produces saber-sheath type TBM while 25% and 50% circumferential cartilage resection produce circumferential TBM. Stent testing enabled the selection of stent design parameters such that airway collapse associated with moderate and severe TBM could be reduced to conform to, but not exceed, that of intact tracheas (12mm pitch, 0.6mm wire diameter).<br /><b>Conclusion</b><br />The ex vivo trachea model is a robust platform that enables systematic study and treatment of different grades and morphologies of airway collapse and TBM. It is a novel tool for optimization of stent design before advancing to in vivo animal models.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Limited Cumulative Experience with Ex-vivo Lung Perfusion is Associated with Inferior Outcomes After Lung Transplantation.</h4><i>Chen Q, Malas J, Krishnan A, Thomas J, ... Bowdish ME, Catarino P</i><br /><b>Objective</b><br />Ex-vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes.<br /><b>Methods</b><br />We identified 9708 isolated, first-time adult lung transplants from the United Network for Organ Sharing database (3/1/2018-3/1/2022), 553 (5.7%) involved using donor lungs after EVLP. Using the total volume of EVLP lung transplants per center during the study period, centers were dichotomized into low (1-15 cases) and high-volume (>15 cases) EVLP centers.<br /><b>Results</b><br />Forty-one centers performed EVLP lung transplants, including 26 low-volume and 15 high-volume centers (median volume 3 vs. 23 cases, p<0.001). Recipients at low-volume centers (n=109) had similar baseline comorbidities compared to high-volume centers (n=444). Low-volume centers used numerically more donation after circulatory death (DCD) donors (37.6 vs. 28.4%, p=0.06) and more donors with PaO<sub>2</sub>/FiO<sub>2</sub> (P/F) ratio <300 (24.8 vs. 9.7%, p<0.001). After EVLP lung transplants, low-volume centers had worse 1-year survival (77.8% vs. 87.5%, p=0.007), with an adjusted hazard ratio (aHR) of 1.63 (95% CI 1.06-2.50, adjusting for recipient age, sex, diagnosis, lung allocation score, DCD donor, donor P/F ratio, and total annual lung transplant volume per center). When compared to non-EVLP lung transplants, 1-year survival of EVLP lung transplants was significantly worse at low-volume centers (aHR 2.09, 95% CI 1.47-2.97) but similar at high-volume centers (aHR 1.14, 95% CI 0.82-1.58).<br /><b>Conclusion</b><br />The use of EVLP in lung transplantation remains limited. Increasing cumulative EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts. (249/250 words).<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Natural History of Aortic Root Dilatation and Pathologic Aortic Regurgitation in Tetralogy of Fallot and its Morphological Variants.</h4><i>Sengupta A, Lee JM, Gauvreau K, Colan SD, ... Mayer JE, Nathan M</i><br /><b>Objective</b><br />We sought to characterize the natural history of aortic root dilatation and aortic regurgitation (AR) in tetralogy of Fallot (TOF).<br /><b>Methods</b><br />A single-center review of patients who underwent TOF repair from 01/1960-12/2022 was performed. Morphology was categorized as TOF-pulmonary stenosis (TOF-PS) or TOF-variant (including TOF-pulmonary atresia and TOF-pulmonary atresia-major aortopulmonary collateral arteries). Echocardiographically-determined diameters and derived z-scores were measured at the annulus, sinus of Valsalva (SoV), and sinotubular junction (STJ) immediately before TOF repair and throughout follow-up. Linear mixed-effects models assessed trends in dimensions over time.<br /><b>Results</b><br />Of 2205 patients that underwent primary repair at a median age of 4.9 (IQR 2.3-20.5) months and survived to discharge, 1608 (72.9%) had TOF-PS and 597 (27.1%) had TOF-variant. At a median postoperative follow-up of 14.4 (IQR: 3.3-27.6; range: 0.1-62.6) years, 313 (14.2%) had ≥mild AR and 34 (1.5%) required an aortic valve or root intervention. The overall mean rates of annular, SoV, and STJ growth were 0.5±0.2, 0.6±0.3, and 0.7±0.5 mm/year, respectively. Root z-scores remained stable with time. At baseline, TOF-variant patients had larger diameters and z-scores at the annulus, SoV, and STJ, compared to TOF-PS patients (all p<0.05). Over time, TOF-variant patients demonstrated relatively greater annular (p=0.020), SoV (p<0.001), and STJ (p<0.001) dilatation. Patients with ≥75<sup>th</sup> percentile root growth rates had a higher incidence of ≥mild AR (p<0.001), ≥moderate AR (p<0.001), and aortic valve repair or replacement (p=0.045).<br /><b>Conclusions</b><br />Patients with TOF-variant are at comparatively greater risk of pathologic root dilatation over time, warranting closer longitudinal follow-up.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Assessment of the Well-being of Significant Others of Cardiothoracic Surgeons.</h4><i>Ungerleider JD, Ungerleider RM, James L, Wolf A, ... Bremner K, Bremner RM</i><br /><b>Objectives</b><br />We aimed to evaluate how the current working climate of cardiothoracic surgery and burnout experienced by cardiothoracic surgeons affects their spouses and significant others (SOs).<br /><b>Methods</b><br />A 33-question well-being survey was developed by the American Association for Thoracic Surgery (AATS) Wellness Committee and distributed by email to the SOs of cardiothoracic surgeons and to all surgeon registrants of the 2020 and 2021 AATS annual meetings with a request to share it with their SO. The 5-item Likert-scale survey questions were dichotomized, and associations were determined by chi-square or independent samples t-tests, as appropriate.<br /><b>Results</b><br />Responses from 238 SOs were analyzed. Sixty-six percent reported that the stress on their cardiothoracic surgeon partner had a moderate to severe impact on their family, and 63% reported that their partner\'s work demands didn\'t leave enough time for family. Fifty-one percent reported that their partner rarely had time for intimacy, 27% reported poor work-life balance, and 23% reported that interactions at home were usually or always not good-natured. SOs were most affected when their partner was less than 5 years out from training, worked in private vs. academic practice, and worked longer hours. Having children, particularly less than 19 years old, and a lack of workplace support resources further diminished well-being.<br /><b>Conclusions</b><br />The current work culture of cardiothoracic surgeons adversely affects their SOs, and the risk for families is concerning. These data present a major area for exploration as we strive to understand and mitigate the factors that lead to burnout among CT surgeons.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Aortic Valve Regurgitation following Transaortic Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy - Incidence and Impact on Late Outcomes.</h4><i>Juarez-Casso FM, Schaff HV, Patlolla SH, Todd A, ... Nishimura RA, AATS Meeting Presentation</i><br /><b>Objective</b><br />In this study, we describe the incidence, sites of valve injury, and the impact of aortic valve regurgitation (AR) on outcomes of septal myectomy for obstructive hypertrophic cardiomyopathy (HCM).<br /><b>Methods</b><br />We analyzed patients who underwent transaortic septal myectomy for obstructive HCM from 2001 to 2022. The primary study endpoint was incidence of procedure-related AR, defined as the need for an unplanned aortic valve (AV) procedure or new-onset moderate AR on early postoperative echocardiography.<br /><b>Results</b><br />There were 2807 patients who underwent transaortic septal myectomy for HCM and had pre- and post-operative transthoracic echocardiograms. Procedure-related AR was observed in 55 (2%) patients; 27 (1%) required unplanned AV procedures at the time of myectomy, and 29 (1%) additional patients developed moderate AR postoperatively. During follow-up, 9 total patients underwent late AV reoperation; one patient who developed new moderate AR postoperatively required late AVR due to severe calcific AS; none of the patients who had unplanned AV procedures required late reoperation. The overall cumulative incidence of aortic valve reoperation at 10 and 15 years was 1% and 5%. The predicted probability of moderate or severe AR at 5 and 10 years was 1.4% and 1.8%. There was no difference in survival comparing patients with or without early postoperative mild or worse AR (p=0.69).<br /><b>Conclusions</b><br />Procedure-related AR was observed in 2% of patients undergoing transaortic septal myectomy, and unplanned AV procedures were necessary for half of these patients. Intraoperative identification and valve repair mitigate the impact of cusp injury on late reintervention and survival.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Predictors of Re-intervention in Atrioventricular Canal Defect Patients Undergoing Left Atrioventricular Valve Repair.</h4><i>Gellis L, McGeoghegan P, Lu M, Feins E, ... Friedman K, Baird C</i><br /><b>Objective</b><br />Acute outcomes after atrioventricular canal defects (AVCD) repair in the current era are excellent, yet despite surgical advances, ∼15% of patients require future left atrioventricular valve (LAVV) repair. Among AVC patients who undergo LAVV repair after primary AVC repair, we sought to characterize the durability of these repairs. Specifically, we aimed to determine predictors for re-intervention following a LAVV repair in repaired AVCD patients, with a focus on postoperative transesophageal echocardiography (TEE).<br /><b>Methods</b><br />We reviewed all patients undergoing LAVV repair (after a primary AVCD repair) at Boston Children\'s Hospital between 2010-2020. Competing risk analysis was performed to evaluate cumulative incidence of LAVV re-interventions. Predictors of LAVV re-intervention were evaluated using multivariable Cox regression.<br /><b>Results</b><br />A total of 137 LAVV repairs following primary AVCD repair were performed in 113 patients. Median age and weight at LAVV repair were 25 months (interquartile range (IQR) 12-76 months) and 11.1 kg (IQR 7.8-19.4 kg). Original anatomy was complete AVCD in 87 (63%), transitional AVCD in 27 (20 %) and partial AVCD in 23 (17 %) cases. Over a median follow-up of 12 months (IQR 1.3 months to 4 years), 47 (34%) of the LAVV repairs required LAVV re-intervention. Re-interventions included a total of 27 LAVV re-repairs and 20 LAVV replacements. In multivariable analysis, age at LAVV repair < 72 months, original partial AVCD anatomy, and LV dysfunction, mean LAVV stenosis gradient > 5 mmHg and multiple jets of regurgitation on post op LAVV repair TEE were associated with LAVV re-intervention. Grade of LAVV regurgitation (LAVVR) on postoperative TEE was not an independent risk factor, but re-intervention rates were high when residual LAVV stenosis gradient was ≥ 5 mmHg and residual mild LAVVR were present on postop TEE (47%) and even higher when residual LAVV stenosis gradient ≥ 5 mmHg and > mild LAVVR(73%).<br /><b>Conclusions</b><br />Re-intervention rates remain high for LAVV repairs that occur after primary AVCD repair, particularly for patients with LAVV stenosis gradient ≥ 5 mmHg and ≥ mild LAVVR on postoperative TEE.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Outcomes of Quantitative Flow Ratio Based Functional Incomplete Revascularization after Coronary Artery Bypass Grafting Surgery.</h4><i>Tian M, Xu B, Chen L, Wu F, ... Wang X, Hu S</i><br /><b>Objective</b><br />Quantitative flow ratio (QFR) is a novel functional assessment tool of coronary diseases. Whether QFR could improve the outcomes of coronary artery bypass grafting (CABG) is undetermined. This study aimed to investigate the association between the QFR based functional incomplete revascularization (ICR) and the outcomes after CABG surgery.<br /><b>Methods</b><br />The QFR assessment was retrospectively performed in patients receiving CABG surgery in the PATENCY trial. The anatomical complete revascularization (CR) denoted revascularizing each territory with stenosis> 50% evaluated by angiography. The functional CR was defined as grafting all vessels with a QFR ≤0.80. The primary endpoint was the 12-month composite major adverse cardiac or cerebral vascular events (MACCE).<br /><b>Results</b><br />2024 patients with available QFR values were included. Functional CR was achieved in 1846 patients (91.2%), and 1600 received anatomical CR (79.1%). Both the functional ICR and anatomical ICR groups were associated with significantly increased risks of 12-month MACCE. (Functional: hazard ratio (HR), 2.91; 95% confidence interval (CI), 1.56-5.43; p=0.001; anatomical: HR, 2.82; 95% CI, 1.54-5.16; p=0.001). Additionally, for the subgroup of patients (n=246) receiving anatomical ICR but judged as functional CR by QFR, the risk of the 12-month MACCE was not significantly increased (adjusted HR, 1.36; 95% CI, 0.71-2.60; p=0.35).<br /><b>Conclusions</b><br />Both the functional ICR and anatomical ICR were associated with increased risks of 12-month MACCE after CABG surgery. The QFR can serve as a supplementary tool for the decision-making of surgical revascularization.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Quantitative Flow Ratio and Graft Outcomes of Coronary Artery Bypass Grafting Surgery: A Retrospective Study.</h4><i>Tian M, Xu B, Chen L, Wu F, ... Wang X, Hu S</i><br /><b>Objective</b><br />Quantitative flow ratio (QFR) is a novel noninvasive tool for the functional assessment of coronary stenosis. Whether QFR could predict graft outcomes after coronary artery bypass grafting (CABG) is unknown. This study aimed to investigate the association of QFR value with graft outcomes after CABG surgery.<br /><b>Methods</b><br />The QFR values were retrospectively obtained from patients receiving CABG surgery from 2017 to 2019 in the PATENCY trial. QFR calculation was conducted in eligible coronary arteries, defined as those with ≥50% stenosis and a diameter ≥1.5 mm. A threshold of QFR≤0.80 was considered functionally significant stenosis. The primary outcome was graft occlusion at 12 months evaluated by computed tomography (CT) angiography.<br /><b>Results</b><br />2024 patients with 7432 grafts (2307 arterial grafts and 5125 vein grafts) were included. For the arterial grafts, the risk of 12-month occlusion was significantly increased in the QFR>0.80 group than in the QFR≤0.80 group (7.1% vs. 2.6%, p=0.001; unadjusted model: odds ratio (OR), 3.08; 95% confidence interval (CI), 1.65-5.75; fully adjusted model: OR, 2.67; 95% CI, 1.44-4.97). No significant association was observed in the vein grafts (4.6% vs. 4.3%, p=0.67; unadjusted model: OR, 1.10; 95% CI, 0.82 -1.47; fully adjusted model: OR, 1.12; 95% CI, 0.83 -1.51). Results were stable across sensitivity analyses with a QFR threshold of 0.78 and 0.75.<br /><b>Conclusions</b><br />Target vessel QFR>0.80 was associated with a significantly higher risk of arterial graft occlusion at 12 months after CABG surgery. No significant association was found between target lesion QFR and vein graft occlusion.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Hemiarch versus Extended Arch Repair for Acute Type A Dissection: Results from a Multicenter National Registry.</h4><i>Elbatarny M, Stevens LM, Dagenais F, Peterson MD, ... Ouzounian M, CTAC Investigators</i><br /><AbstractText>We compared perioperative outcomes of Acute Type A Aortic Dissection (ATAD) patients undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention. 929 patients underwent ATAD repair (2002 - 2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included: elephant trunk, antegrade TEVAR, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, CT malperfusion resolution, and a composite. Multivariable logistic regression was also performed. Mean age was 66±18 years, 30% (278/929) were women, and HA was performed more frequently (75%, n=695) than EA (25%, n=234). EAD techniques included: dissection stent (39/234, 17%), TEVAR (18/234, 7.7%), and elephant trunk (87/234, 37%). In-hospital mortality [EA: n=49, 21%; HA: n=129, 19%, p=0.42], and neurological deficit [EA: n= 43, 18%; HA: n=121, 17%, p=0.74] were similar. EA was not independently associated with death [EA vs HA OR: 1.09 (0.77-1.54), p=0.63] or neurologic deficit [EA vs HA OR: 0.85 (0.47 - 1.55), p=0.59]. Composite adverse events differed significantly [EA vs HA OR: 1.47 (1.16 - 1.87) p=0.001]. Malperfusion resolved more frequently after EAD [EAD: n=32 (80%), EAND: n=18 (56%), HA: n=71 (50%), p=0.004], though multivariable analysis was not significant [EAD vs HA OR: 2.17 (0.83 - 5.66), p=0.10]. Extended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Gender Differences in Cardiothoracic Surgery Letters of Recommendation.</h4><i>Yong V, Rostmeyer K, Deng M, Chin K, ... Ma GX, Erkmen CP</i><br /><b>Objective</b><br />To investigate if gender influences letters of recommendation for cardiothoracic surgery fellowship.<br /><b>Methods</b><br />From applications to an Accreditation Council Graduate Medical Education cardiothoracic surgery fellowship program between 2016 and 2021, applicant and author characteristics were examined with descriptive statistics, analysis of variance, and Pearson-Chi square tests. Linguistic software was used to assess communication differences in letters of recommendation, stratified by author and applicant gender. An additional higher-level analysis was then performed using a Generalized Estimating Equations model to examine linguistic differences among author-applicant gender pairs.<br /><b>Results</b><br />739 recommendation letters extracted from 196 individual applications were analyzed; 90% (n=665) of authors were men and 55.8% (n=412) of authors were cardiothoracic surgeons. Compared to women authors, authors who are men wrote more authentic (p=0.01) and informal (p=0.03) recommendation letters. When writing for women applicants, authors who are men were more likely to display their own leadership and status (p=0.03) and discuss women applicants\' social affiliations (p=0.01), like occupation of applicant\'s father or husband. Women authors wrote longer letters (p=0.03) and discussed applicants\' work (p=0.01) more often than authors who are men. They also mentioned leisure activities (p=0.03) more often when writing for women applicants.<br /><b>Conclusions</b><br />Our work identifies gender-specific differences in letters of recommendation. Women applicants may be disadvantaged because their recommendation letters are significantly more likely to focus on their social ties, leisure activities, and the status of the letter writer. Author and reviewer awareness of gender-biased use of language will aid in improvements to the candidate selection process.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Apr 2023; epub ahead of print</small></div>

<div><h4>Exogenous Nitric Oxide Delivery Protects Against Cardiopulmonary Bypass-Associated Acute Kidney Injury: Histologic and Serologic Evidence from an Ovine Model.</h4><i>Greenberg JW, Hogue S, Raees MA, Ahmed HF, ... Morales DLS, Cooper DS</i><br /><b>Objective</b><br />Several human studies have associated nitric oxide (NO) administration via the cardiopulmonary bypass-(CPB) circuit with decreased incidence of CPB-associated acute kidney injury-(AKI), but histopathologic and serologic evidence of NO efficacy for AKI attenuation are lacking.<br /><b>Methods</b><br />Using a survival ovine model (72 hr), AKI was induced by implementing low-flow CPB for two hours, followed by full-flow CPB for two hours. The NO cohort (n=6) received exogenous NO through the CPB circuit via the oxygenator and the control group (n=5) received no NO. Serial serologic biomarkers and renal histopathology were obtained.<br /><b>Results</b><br />Baseline characteristics ( age, weight) and intraoperative parameters (CPB time, urine output [UOP], heart rate, arterial pH & lactate) were equivalent (p>0.10) between groups. Postoperatively, UOP, heart rate, respiratory rate, and SpO<sub>2</sub> were equivalent (p>0.10) between groups. Post-CPB creatinine elevations from baseline were significantly greater in control vs. NO group at 16, 24, and 48 hours (all p<0.05). Histopathologic evidence of moderate/severe AKI (epithelial necrosis, tubular slough, cast formation, glomerular edema) occurred in 60% (3/5) control vs. 0% (0/6) NO animals. Cortical tubular epithelial cilia lengthening (a sensitive sign of cellular injury) was significantly greater in the control group than the NO group (p=0.012).<br /><b>Conclusions</b><br />In a survival ovine CPB model, NO administered with CPB demonstrated serologic and histologic evidence of renal protection from AKI. These results provide insight into one potential mechanism for CPB-associated AKI and supports continued study of NO via CPB circuit for prevention of AKI.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Apr 2023; epub ahead of print</small></div>

<div><h4>Risk Profile And Operative Outcomes In Marfan Syndrome Versus Non-Marfan Patients Undergoing Thoracoabdominal Aortic Aneurysm Repair.</h4><i>Lau C, Soletti G, Weinsaft JW, Rahouma M, ... Gaudino M, Girardi LN</i><br /><b>Objectives</b><br />To compare operative and long-term outcomes between Marfan and non-Marfan patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair.<br /><b>Methods</b><br />We identified all consecutive patients undergoing TAAA repair between 1997 and 2022. Primary outcome was composite of major adverse events (MAE). Secondary outcomes were individual complications and long-term survival. Inverse probability of treatment weighting was performed. Weighted Kaplan-Meier (KM) curves were used to estimate long-term survival. Multivariable analysis identified factors associated with MAE.<br /><b>Results</b><br />684 patients underwent open TAAA repair. 90 (13.1%) had Marfan syndrome, while 594 (86.9%) did not. Marfan patients were younger (46[36-56] vs 69[61-76], p<0.001). Extent II-III aneurysms (57/90, 63.3% vs 211/594, 35.6%, p<0.001) and type I or III chronic dissection (77/90, 85.3% vs 242/594, 40.8%, p<0.001) were more common. Cardiovascular risk factors were less frequent in Marfan patients. There was no difference in MAE between groups (12/90, 13.3% vs 100/594, 16.8%, p=0.49). Operative mortality was similar between groups (3/90, 3.3% vs 28/594, 4.7%, p=0.75). Unweighted survival at 10 years was 78.7% vs 46.8% (p=0.001). Weighted KM curves showed no difference in long-term survival (adjusted HR 0.79; CI 0.32-1.99, p=0.62; Log-rank p=0.12). At multivariable analysis, renal insufficiency (OR 2.29; CI 1.43-3.68, p<0.01) and urgent/emergent procedure (OR 2.17; CI 1.35-3.48, p<0.01) were associated with MAE, while Marfan syndrome was not (OR 1.56; CI 0.69-3.49, p=0.28).<br /><b>Conclusions</b><br />Open TAAA repair can be performed with similar operative outcomes in Marfan and non-Marfan patients despite differing risk profiles. Operative/perioperative strategies must be tailored to specific needs of the patient to optimize outcomes.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Apr 2023; epub ahead of print</small></div>

<div><h4>Aortic valve repair versus the Ross procedure in children.</h4><i>Zhu MZL, Konstantinov IE, Wu DM, Wallace FRO, Brizard CP, Buratto E</i><br /><b>Background</b><br />Aortic valve repair and Ross procedure (RP) are widely used in children; however, it is unclear which provides the best outcomes.<br /><b>Methods</b><br />Patients who underwent primary aortic valve surgery from 1980 to the 2018 were included. Propensity-score matching was performed to adjust for baseline differences.<br /><b>Results</b><br />Of 415 children, 82.7% (343/415) underwent repair, and 17.3% (72/415) underwent RP. At 15-years, survival was higher for aortic valve repair (93.9±1.8% v 80.9±6.4%, p=0.04), freedom from reoperation (45.7±4.9% v 48.5±9.0%, p=0.29) did not differ and, freedom from aortic valve reoperation was higher in the RP group (45.7±4.9% v 70.7±8.0%, p<0.001). When analyzed by quality of repair, acceptable repair provided the highest survival (p=0.01). Acceptable repair and RP had similar freedom from reoperation at 15-years, while suboptimal repair performed worse (acceptable: 54.9±6.7%; RP: 48.5%±9.0; suboptimal: 27.0±7.7%, p<0.001). Acceptable repair and RP had similar freedom from aortic valve reoperation at 15-years, while suboptimal repair performed worse (acceptable: 54.9±6.7; RP: 70.7%±8.0; suboptimal: 27.0±7.7%, p<0.001). Propensity-score matching paired 66 RP with 198 repair patients. At 15-years, repair was associated with better survival (98.0±1.2% vs 78.5±7.2%, p=0.03), while freedom from reoperation was similar (42.6±7.6% vs 50.7±9.8%, p=0.50). However, RP was associated with higher freedom from aortic valve reoperation (42.6±7.6% vs 72.3±8.5%, p=0.002).<br /><b>Conclusions</b><br />Primary aortic valve repair was associated with better survival than RP, while overall freedom from reoperation was similar. When an acceptable intraoperative result was achieved, outcomes of repair were favorable. However, when the intraoperative result of repair was suboptimal, the Ross procedure performed better.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Apr 2023; epub ahead of print</small></div>

<div><h4>Association of Adherence to Individual Components of STS Cardiac Surgery Antibiotic Guidelines and Post-operative Infections.</h4><i>Bardia A, Michel G, Farela A, Fisher C, ... Geirsson A, Schonberger RB</i><br /><b>Objectives</b><br />To measure the association among the four components of STS antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve and/or CABG requiring cardiopulmonary bypass.<br /><b>Methods</b><br />In this retrospective observational study, adult patients undergoing coronary revascularization and/or valvular surgery who received a SCIP-compliant antibiotic from 01/01/2016 to 04/01/2021 at a single, tertiary care hospital were included. The primary exposures were adherence to the four individual components of STS antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by STS data-abstractors, controlling for several known confounders.<br /><b>Results</b><br />Of the 2829 included patients, 1084 (38.3%) received care that was non-adherent to at least one aspect of STS antibiotic guidelines. The incidence of non-adherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with STS-adjudicated postoperative infection (OR 1.9; 95%CI 1.1-3.3; p=0.02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (OR 6.9; 95%CI 2.5-8.5; p<0.01) and 30-day mortality (OR 4.3; 95%CI 1.7-11.4; p< 0.01). No other significant associations between the four STS metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality.<br /><b>Conclusions</b><br />Non-adherence to STS antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing are associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 17 Apr 2023; epub ahead of print</small></div>

<div><h4>Septal Annular Dilation in Chronic Ovine Functional Tricuspid Regurgitation.</h4><i>Iwasieczko A, Jazwiec T, Gaddam M, Gaweda B, ... Rausch MK, Timek TA</i><br /><b>Introduction</b><br />Annular reduction with prosthetic rings represents current surgical treatment of functional tricuspid regurgitation (FTR). However, alterations of annular geometry and dynamics associated with FTR are not well characterized.<br /><b>Methods</b><br />FTR was induced in 29 adult sheep with either eight weeks of pulmonary artery banding (PAB, n=15) or 3 weeks of tachycardia induced cardiomyopathy (TIC, n=14). Eight healthy sheep served as controls (CTL). At terminal procedure, all animals underwent sternotomy, epicardial echocardiography, and implantation of sonomicrometry crystals on the tricuspid annulus (TA) and RV free wall while on cardiopulmonary bypass. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were acquired after weaning from CPB and stabilization. Annular geometry and dynamics were calculated from 3D crystal coordinates.<br /><b>Results</b><br />Mean FTR grade (0-4) was 3.2±1.2 and 3.2±0.5 for PAB and TIC, respectively with both models of FTR associated with similar degree of RV dysfunction (RVFAC 38±7% and 37±9% for PAB and TIC, respectively). LV ejection fraction was significantly reduced in TIC versus baseline (33±9%, vs 58±4%, p=0.0001). TA area was 651±109, 881±242, and 995±232 mm<sup>2</sup> for CTL, FTR, and TIC, respectively (p=0.006) with TA area contraction of 16.6±4.2, 11.5±8.0, and 6.0±4.0%, respectively (p=0.003). Septal annulus increased from 33.8±3.1 to 39.7±6.4 and 43.1±3.2 mm for CTL, PAB, and TIC, respectively (p<0.0001).<br /><b>Conclusion</b><br />Ovine FTR was associated with annular dilation and reduced annular area contraction. Significant dilation of septal annulus was observed in both models of FTR. As tricuspid rings do not completely stabilize the septal annulus, continued remodeling may contribute to recurrent FTR after repair.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 13 Apr 2023; epub ahead of print</small></div>

<div><h4>Left atrial appendage closure during mitral repair in patients without atrial fibrillation.</h4><i>Chikwe J, Roach A, Emerson D, Chen Q, ... Egorova N, Trento A</i><br /><b>Objective</b><br />Routine left atrial appendage closure during mitral repair in patients without atrial fibrillation (AF) is controversial. We aimed to compare the incidence of stroke after mitral repair in patients without recent AF according to left atrial appendage closure.<br /><b>Methods</b><br />An institutional registry identified 764 consecutive patients without recent AF, endocarditis, prior appendage closure, or stroke undergoing isolated robotic mitral repair between 2005-2020. Left atrial appendages were closed via left atriotomy using a double-layer continuous suture in 5.3% (15/284) patients before 2014, versus 86.7% (416/480) after 2014. The cumulative incidence of stroke (including transient ischemic attack[TIA]) was determined using state-wide hospital data. Median follow-up was 4.5 (range 0-16.6) years.<br /><b>Results</b><br />Patients undergoing left atrial appendage closure were older (63 vs. 57.5 years, p<0.001), with higher prevalence of remote AF requiring cryomaze (9%, n=40 vs 1%, n=3, p<0.001). After appendage closure there were fewer reoperations for bleeding (0.7%, n=3 vs 3% ,n=10, p=0.02), and more AF (31.8%, n=137 vs 25.2%, n=84, p=0.047). Two-year freedom from >2+ mitral regurgitation was 97%. Six strokes and one transient ischemic attack occurred after appendage closure compared to fourteen and five in patients without (p=0.002): associated with a significant difference in 8-year cumulative incidence of stroke/TIA (hazard ratio 0.3, 95% confidence interval 0.14-0.85, p=0.02). This difference persisted in the sensitivity analysis excluding patients undergoing concomitant cryomaze procedures.<br /><b>Conclusions</b><br />Routine left atrial appendage closure during mitral repair in patients without recent AF appears safe and was associated with a lower risk of subsequent stroke/TIA.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 04 Apr 2023; epub ahead of print</small></div>

<div><h4>Clinical and financial outcomes of pulmonary resection for lung cancer in safety-net hospitals.</h4><i>Sakowitz S, Verma A, Mabeza RM, Cho NY, ... Toste P, Benharash P</i><br /><b>Objective</b><br />Safety-net hospitals (SNHs) have previously been associated with inferior outcomes and greater resource use. However, this relationship has not been explored in the contemporary setting of pulmonary lobectomy. In the present national study we characterized the association between SNHs and mortality, complications, and resource use.<br /><b>Methods</b><br />All adults (18 years of age or older) who underwent elective lobectomy for lung cancer were identified within the 2010 to 2019 Nationwide Readmissions Database. Hospitals in the highest quartile of safety-net burden were categorized as SNHs, and others non-SNHs. Multivariable regressions were developed to assess the independent association between safety-net status and outcomes of interest.<br /><b>Results</b><br />Of an estimated 282,011 patients who met inclusion criteria, 41,015 (14.5%) were treated at SNHs. Patients at SNHs were younger but as commonly female, compared with non-SNHs. After multivariable adjustment, there was no association between SNHs and mortality. However, treatment at SNHs was linked to higher odds of pneumonia (adjusted odds ratio [AOR], 1.11; 95% CI, 1.02-1.21) and prolonged ventilation (AOR, 1.36; 95% CI, 1.11-1.66), as well as infectious (AOR, 1.24; 95% CI, 1.08-1.43), intraoperative (AOR, 1.22; 95% CI, 1.07-1.39), and overall complications (AOR, 1.07; 95% CI, 1.01-1.14). Patients at SNHs also showed a greater need for a blood transfusion (AOR, 1.37; 95% CI, 1.23-1.53). In addition, SNHs were associated with increased length of stay (+0.33 days; 95% CI, 0.17-0.48) and greater costs (+$4130; 95% CI, 3.34-4.92), relative to non-SNHs.<br /><b>Conclusions</b><br />Hospital safety-net status was associated with greater odds of perioperative complications and greater health care expenditure. Further investigation is necessary uncover the mechanisms contributing to these complications and eradicate persistent disparities in lobectomy.<br /><br />Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Apr 2023; 165:1577-1584.e1</small></div>

<div><h4>Coronary surgery provides better survival than drug eluting stent: a pooled meta-analysis of Kaplan-Meier-derived individual patient data.</h4><i>Urso S, Sadaba R, González Martín JM, Dayan V, ... Abad C, Portela F</i><br /><b>Objectives</b><br />we explored the current evidence on coronary disease treatment comparing the survival of two therapeutic strategies: coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug eluting stent (DES).<br /><b>Methods</b><br />PubMed, Embase, and Google Scholar were searched for randomized clinical trials (RCTs) comparing CABG versus PCI with DES. The endpoint was overall mortality. Two statistical approaches were used: the generic inverse variance method, which was used to pool the incident rate ratios (IRRs), and the pooled meta-analysis of Kaplan-Meier-derived individual patient data (IPD).<br /><b>Results</b><br />eight RCTs comparing 4975 patients undergoing CABG and 4992 patients undergoing PCI were included in our meta-analysis. Generic inverse variance method showed a statistically significant survival benefit of the CABG group (IRR 1.21, 95% CI 1.09-1.35; P <0.01). The Kaplan-Meier estimates of survival at 1, 5 and 10 years of the CABG group were 97.1%, 90.3% and 80.3%, respectively. The Kaplan-Meier estimates of survival at 1, 5 and 10 years of the PCI group were 97.0%, 87.7% and 76.4% respectively. The log-rank analysis confirmed a statistically significant benefit in term of overall mortality of the CABG group (HR 1.24; 95% CI 1.11-1.38; P 0.0001).<br /><b>Conclusion</b><br />The present meta-analysis suggests that CABG provides a consistent survival benefit over percutaneous coronary intervention with drug eluting stent.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 29 Mar 2023; epub ahead of print</small></div>

<div><h4>Threats and Opportunities - Public Reporting in Congenital Heart Surgery.</h4><i>Caldarone CA, Romano JC, Jaquiss RD, Bacha E, Dearani JA, Overman DM</i><br /><AbstractText>Public reporting of outcomes in congenital heart surgery has provided transparency and an important stimulus for improvement. There are, however, unintended consequences of public reporting and associated public ranking which adversely affect quality of care and thereby threaten our patients. This manuscript provides a description of these unintended consequences and proposes some potential solutions to transform unintended consequences into positive incentives which would improve quality of care. The proposed remedies are not expected to be complete solutions - instead, they are put forward to initiate public discourse, elicit new ideas, and hopefully lead us to creative solutions that transform these threats into opportunities.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Mar 2023; epub ahead of print</small></div>

<div><h4>Characteristics of Donor Lungs Declined On-Site and Impact of Lung Allocation Policy Change.</h4><i>Terada Y, Takahashi T, Hachem RR, Liu J, ... Kreisel D, Puri V</i><br /><b>Objective</b><br />National and institutional data suggest an increase in organ discard rate (donor lungs procured but not implanted) after a new lung allocation policy was introduced in 2017. However, this measure does not include on-site decline rate (donor lungs declined intraoperatively). The objective of this study is to examine the impact of the allocation policy change on on-site decline.<br /><b>Methods</b><br />We utilized a Washington University (WU) and our local organ procurement organization (Mid America Transplant [MTS]) database to abstract data on all accepted lung offers from 2014 to 2021. An on-site decline was defined as an event where the procuring team declined the organs intraoperatively, and the lungs were not procured. Logistic regression models were used to investigate potentially modifiable reasons for decline.<br /><b>Results</b><br />The overall study cohort comprised of 876 accepted lung offers of which 471 donors were at MTS with WU or others as the accepting center and 405 at other OPOs with WU as the accepting center. At MTS, the on-site decline rate increased from 4.6 to 10.8% (p=0.01) after policy change. Given the greater likelihood of non-local organ placement and longer travel distance after policy change, the estimated cost of each on-site decline increased from $5,727 to $9,700. In the overall group, latest PaO2 (odds ratio (OR) 0.993, confidence interval (CI): 0.989-0.997), chest trauma (OR 2.474, CI: 1.018-6.010), chest X-ray abnormality (OR 2.902, CI: 1.289-6.532), and bronchoscopy abnormality (OR 3.654, CI: 1.813-7.365) were associated with on-site decline, though lung allocation policy era was unassociated (p=0.22) <br /><b>Conclusions:</b><br/>We found that nearly 8% of accepted lungs are declined on-site. Several donor factors were associated with on-site decline, though lung allocation policy change did not have a consistent impact on on-site decline.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 27 Mar 2023; epub ahead of print</small></div>

<div><h4>Neoadjuvant therapy does not increase postoperative morbidity of sleeve lobectomy in locally advanced non-small cell lung cancer.</h4><i>Li X, Li Q, Yang F, Gao E, ... Song X, Duan L</i><br /><b>Objectives</b><br />To evaluate the feasibility and safety of sleeve lobectomy after neoadjuvant therapy by assessing the postoperative morbidity.<br /><b>Methods</b><br />Patients who underwent sleeve lobectomy for non-small cell lung cancer (NSCLC) were retrospectively analyzed from January 2018 to December 2021. A total of 613 patients were enrolled, including 124 patients who received prior neoadjuvant therapy and 489 patients who did not. Propensity score matching (PSM) was adopted to create a balanced cohort consisting of 97 paired cases. Patient demographics and perioperative outcomes were compared between the two groups, and logistic regression analysis was used to identify risk factors for postoperative complications.<br /><b>Results</b><br />In the entire cohort, univariable logistic regression analysis showed that smoking history (OR=1.501, 95%CI:1.011-2.229, P=0.044), open thoracotomy (OR=1.748, 95%CI: 1.178-2.593, P=0.006), and operation time more than 150 minutes (OR=1.548, 95%CI:1.029-2.328, P=0.036) were risk factors for postoperative complications, and multivariable logistic regression analysis showed open thoracotomy was an independent risk factor (OR=1.765, 95%CI:1.178-2.643, P=0.006). In the balanced cohort, the neoadjuvant group had a lower proportion of double-sleeve resections (3.1% vs 11.3%, P=0.035) and longer postoperative chest tube drainage (6.67±3.81 vs 5.13±3.74 days, P＜0.001). However, no significant differences were observed in postoperative morbidity between the two groups (25.8% vs 24.7%, P=0.869). The complete pathologic response (CPR) of chemoimmunotherapy was significantly superior to chemotherapy alone (28.2% vs 4.1%, P＜0.001), and no significant differences were noted in postoperative morbidity in different neoadjuvant therapy modalities.<br /><b>Conclusions</b><br />After neoadjuvant therapy, sleeve lobectomy can be safely performed with no increased postoperative morbidity.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 23 Mar 2023; epub ahead of print</small></div>

<div><h4>Textbook outcome: A novel metric in heart transplantation outcomes.</h4><i>Zakko J, Premkumar A, Logan AJ, Sneddon JM, ... Ganapathi AM, Schenk AD</i><br /><b>Objective</b><br />Assessing heart transplant program quality using short-term survival is insufficient. We define and validate the composite metric textbook outcome and examine its association with overall survival.<br /><b>Methods</b><br />We identified all primary, isolated adult heart transplants in the United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files from May 1, 2005, to December 31, 2017. Textbook outcome was defined as length of stay 30 days or less; ejection fraction greater than 50% during 1-year follow-up; functional status 80% to 100% at 1 year; freedom from acute rejection, dialysis, and stroke during the index hospitalization; and freedom from graft failure, dialysis, rejection, retransplantation, and mortality during the first year post-transplant. Univariate and multivariate analyses were performed. Factors independently associated with textbook outcome were used to create a predictive nomogram. Conditional survival at 1 year was measured.<br /><b>Results</b><br />A total of 24,620 patients were identified with 11,169 (45.4%, 95% confidence interval, 44.7-46.0) experiencing textbook outcome. Patients with textbook outcome were more likely free from preoperative mechanical support (odds ratio, 3.504, 95% confidence interval, 2.766 to 4.439, P < .001), free from preoperative dialysis (odds ratio, 2.295, 95% confidence interval, 1.868-2.819, P < .001), to be not hospitalized (odds ratio, 1.264, 95% confidence interval, 1.183-1.349, P < .001), to be nondiabetic (odds ratio, 1.187, 95% confidence interval, 1.113-1.266, P < .001), and to be nonsmokers (odds ratio, 1.160, 95% confidence interval,1.097-1.228, P < .001). Patients with textbook outcome have improved long-term survival relative to patients without textbook outcome who survive at least 1 year (hazard ratio for death, 0.547, 95% confidence interval, 0.504-0.593, P < .001).<br /><b>Conclusions</b><br />Textbook outcome is an alternative means of examining heart transplant outcomes and is associated with long-term survival. The use of textbook outcome as an adjunctive metric provides a holistic view of patient and center outcomes.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 23 Mar 2023; epub ahead of print</small></div>

<div><h4>Intra-tracheally injected human induced pluripotent stem cell-derived pneumocytes and endothelial cells engraft in the distal lung and ameliorate emphysema in a rat model.</h4><i>Altalhi W, Wu T, Wojtkiewicz GR, Jeffs S, Miki K, Ott HC</i><br /><b>Objectives</b><br />Pulmonary emphysema is characterized by the destruction of alveolar units and reduced gas exchange capacity. In the present study, we aimed to deliver induced pluripotent stem cell (iPSCs)-derived endothelial cells and pneumocytes to repair and regenerate distal lung tissue in an elastase-induced emphysema model.<br /><b>Methods</b><br />We induced emphysema in athymic rats via intratracheal injection of elastase as previously reported. At 21 and 35 days after elastase treatment, we suspended 80 million iPSCs-derived endothelial cells and 20 million iPSCs-derived pneumocytes in hydrogel and injected the mixture intra-tracheally. On day 49 after elastase treatment, we performed imaging, functional analysis, and collected lungs for histology.<br /><b>Results</b><br />Using immunofluorescence detection of human-specific HLA1, human-specific CD31, and anti-GFP for the reporter labeled pneumocytes, we found that transplanted cells engrafted in 14.69 ± 0.95% of the host alveoli and fully integrated to form vascularized alveoli together with host cells. Transmission electron microscopy confirmed the incorporation of the transplanted human cells and the formation of a blood-air barrier. Human endothelial cells formed perfused vasculature. Computed tomography scans revealed improved vascular density and decelerated emphysema progression in cell-treated lungs. Proliferation of both human and rat cell was higher in cell-treated vs non-treated controls. Cell treatment reduced alveolar enlargement, improved dynamic compliance and residual volume, and improved diffusion capacity.<br /><b>Conclusions</b><br />Our findings suggest that human iPSC-derived distal lung cells can engraft in emphysematous lungs and participate in the formation of functional distal lung units to ameliorate the progression of emphysema.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Randomized Feasibility Trial of Prophylactic Radiofrequency Ablation to Prevent Atrial Fibrillation after Cardiac Surgery.</h4><i>Willekes CL, Fanning JS, Heiser JC, Sang SLW, ... Parker J, Ragagni MK</i><br /><b>Objective</b><br />Evaluate the feasibility of prophylactic radiofrequency isolation of the pulmonary veins, with left atrial appendage amputation, to reduce the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery in patients aged 70 and older.<br /><b>Methods</b><br />The Federal Food and Drug Administration granted an investigational device exemption to utilize a bipolar radiofrequency clamp for prophylactic pulmonary vein isolation in a limited, feasibility trial. Sixty-two patients without prior dysrhythmias, were prospectively randomized to undergo either their index cardiac surgical procedure, or bilateral pulmonary vein isolation and left atrial appendage amputation during their cardiac operation. The primary outcome was occurrence of in-hospital POAF. Subjects were on 24-hour telemetry until discharge. Dysrhythmias, any episode of atrial fibrillation > 30 seconds, were confirmed by electrophysiologists blinded to the study.<br /><b>Results</b><br />Sixty patients, mean age 75 years and mean CHA2DS2-VASc score 4, were analyzed. Thirty-one patients randomized to control and twenty-nine to the treatment group. Majority of cases in each group were isolated CABG. No perioperative complications related to the treatment procedure, need for permanent pacemaker, or mortality occurred. The in-hospital incidence of POAF was 55% (17/31) in the control group and 7% (2/29) in the treatment group. (p<0.001) The control group had a significantly higher requirement for antiarrhythmic medications at discharge, 45% (14/31) vs 7% (2/29) in the treatment group (p<0.001).<br /><b>Conclusions</b><br />Prophylactic radiofrequency isolation of the pulmonary veins with left atrial appendage amputation, during the primary cardiac surgical operation, reduced the incidence of POAF in patients 70 years and older with no history of atrial arrhythmias.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Commentary: Draining the cGAS from Immunity, advancing heart transplant surgery through a translational science approach.</h4><i>Lei I, Tang PC</i><br /><AbstractText>Achieving prolonged donor heart preservation and considerable reductions in primary graft dysfunction will require a multi-pronged approach against a number of key processes. This goal is unlikely to be achieved by intervening on a single pathway or target molecule. Wu et al shows that the cGAS-STING pathway is an important piece of the puzzle in the relentless march toward organ banking. Further work is needed to demonstrate its relevance in human hearts and large animal studies are needed to satisfy the regulatory rigors for reaching clinical translation.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Outcomes of concomitant myectomy and left ventricular apical aneurysm repair in patients with hypertrophic cardiomyopathy.</h4><i>Sun D, Schaff HV, Nishimura RA, Geske JB, Dearani JA, Ommen SR</i><br /><b>Objectives</b><br />Hypertrophic cardiomyopathy with left ventricular apical aneurysm is a phenotype associated with a 4-fold increase in the risk for sudden cardiac death. In this study, we describe the surgical outcome of concomitant apical aneurysm repair in patients undergoing transapical myectomy for hypertrophic cardiomyopathy.<br /><b>Methods</b><br />We identified 67 patients with left ventricular apical aneurysms who underwent transapical myectomy and apical aneurysm repair between July 2000 and August 2020. Long-term survival was compared with that of 2746 consecutive patients undergoing transaortic septal myectomy for obstructive hypertrophic cardiomyopathy with subaortic obstruction.<br /><b>Results</b><br />Transapical myectomy was indicated for midventricular obstruction (n = 44) or left ventricular remodeling for diastolic heart failure (n = 29). Preoperatively, 74.6% (n = 50) of patients were in New York Heart Association class III/IV heart failure, and 34.3% (n = 23) of patients had experienced syncope or presyncope. Atrial fibrillation was documented in 22 patients (32.8%), and episodes of ventricular arrhythmias were recorded in 30 patients (44.8%). Thrombus was present in the apical aneurysm in 6 patients. During a median (interquartile range) follow-up of 4.9 (1.8-7.6) years, the estimated 1- and 5-year survivals were 98.5% and 94.5%, respectively, which were not significantly different from that of patients undergoing transaortic septal myectomy for obstructive hypertrophic cardiomyopathy (P = .52) or an age- and sex-matched US general population (P = .40).<br /><b>Conclusions</b><br />Apical aneurysm repair in conjunction with septal myectomy is a safe procedure, and the good long-term survival of patients suggests that the procedure may reduce cardiac-related death in this high-risk hypertrophic cardiomyopathy population.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 15 Mar 2023; epub ahead of print</small></div>

<div><h4>Independent associations with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms.</h4><i>Köksoy C, Rebello K, Green SY, Amarasekara HS, ... LeMaire SA, Coselli JS</i><br /><b>Objective</b><br />We aimed to identify outcomes and factors that independently associate with early mortality after open repair of Crawford extent IV thoracoabdominal aortic aneurysms (TAAAs), defined as aneurysms confined to the segment below the diaphragm.<br /><b>Methods</b><br />This retrospective analysis included 721 extent IV TAAA repairs performed in our institution from 1986 to 2021. Indications for repair were aneurysm without dissection in 627 cases (87.0%) and aortic dissection in 94 (13.0%). Overall, 466 patients (64.6%) were symptomatic preoperatively; 124 (17.2%) procedures were performed in patients with acute presentation, including 58 (8.0%) ruptured aneurysms.<br /><b>Results</b><br />Operative death occurred after 49 (6.8%) repairs. Persistent renal failure necessitating dialysis occurred after 43 (6.0%) repairs. Binary logistic regression modeling revealed that previous extent II TAAA repair, chronic kidney disease, previous myocardial infarction, urgent or emergency repair, and longer cross-clamp times during surgery were independently associated with operative mortality. Among early survivors (n=672), competing risk regression modeling revealed that cumulative incidence of mortality and reintervention rates at 10 years were 74.8% (95% CI: 71.4%-78.5%) and 3.3% (95% CI: 2.2%-5.1%), respectively.<br /><b>Conclusions</b><br />Although patient comorbidities contributed to operative mortality, factors associated with the repair, such as urgent or emergency status, the duration of aortic cross-clamping, and certain types of complex reoperation, also played prominent roles. Patients who survive the operation can expect a durable repair that usually is free from late reintervention. Expanding our collective knowledge regarding patients who undergo open repair of extent IV TAAAs will enable clinicians to establish best practices and improve patient outcomes.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 15 Mar 2023; epub ahead of print</small></div>

<div><h4>Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement.</h4><i>Moser N, Omar MA, Koshman SL, Lin M, ... Kent W, Harten C</i><br /><b>Objective</b><br />Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation.<br /><b>Methods</b><br />This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates.<br /><b>Results</b><br />A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups.<br /><b>Conclusions</b><br />Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 14 Mar 2023; epub ahead of print</small></div>

<div><h4>Cardiomyocytic cyclic GMP-AMP synthase is critical for the induction of experimental cardiac graft rejection.</h4><i>Wu Z, Miao X, Jiang Y, Kong D, ... Shi B, Gong W</i><br /><b>Objective</b><br />During cardiac transplantation, cellular injury and DNA damage can result in the accumulation of cytosolic double-stranded DNA (dsDNA), which can activate the cyclic GMP-AMP synthase (cGAS)/stimulator of interferon gene (STING) signaling pathway and thus induce multiple proinflammatory responses. However, the role of the cGAS-STING pathway in cardiac transplantation remains unclear. This study explored the role of cardiomyocytic cGAS in mouse heart transplantation during the ischemia/reperfusion and rejection processes.<br /><b>Methods and results</b><br />Cytosolic dsDNA accumulation and cGAS-STING signaling pathway component upregulation were observed in the grafts posttransplantation. The use of cGAS-deficient donor tissues led to significantly prolonged graft survival. The underlying mechanisms involved decreased expression and phosphorylation of downstream proteins, including TANK binding kinase 1 and nuclear factor κB. In parallel, notably diminished expression levels of various proinflammatory cytokines were observed. Accordingly, substantially decreased proportions of macrophages (CD11b<sup>+</sup>F4/80<sup>+</sup>) and CD8<sup>+</sup> T cells were observed in the spleen. The activation of CD8<sup>+</sup> T cells (CD8<sup>+</sup>CD69<sup>+</sup>) within the graft and the proportion of effector memory (CD44<sup>high</sup>CD62L<sup>low</sup>) lymphocytes in the spleen were notably decreased. Treatment with the cGAS inhibitor Ru.521 led to significantly prolonged graft survival.<br /><b>Conclusions</b><br />Cardiomyocytic cGAS plays a critical role by sensing cytosolic dsDNA during cardiac transplantation and could serve as a potential therapeutic target to prevent graft rejection.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 11 Mar 2023; epub ahead of print</small></div>

<div><h4>Effect of leaflet laceration on transcatheter aortic valve replacement fluid mechanics and comparison with surgical aortic valve replacement.</h4><i>Sadri V, Kohli K, Ncho B, Inci EK, ... Babaliaros V, Yoganathan AP</i><br /><b>Background</b><br />Leaflet thrombosis after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) may be caused by blood flow stagnation in the native and neosinus regions. To date, aortic leaflet laceration has been used to mitigate coronary obstruction following TAVR; however, its influence on the fluid mechanics of the native and neosinus regions is poorly understood. This in vitro study compared the flow velocities and flow patterns in the setting of SAVR vs TAVR with and without aortic leaflet lacerations.<br /><b>Methods</b><br />Two valves, (23-mm Perimount and 26-mm SAPIEN 3; Edwards Lifesciences) were studied in a validated mock flow loop under physiologic conditions. Neosinus and native sinus fluid mechanics were quantified using particle image velocimetry in the left and noncoronary cusp, with an increasing number of aortic leaflets lacerated or removed.<br /><b>Results</b><br />Across all conditions, SAVR had the highest average sinus and neosinus velocities, and this value was used as a reference to compare against the TAVR conditions. With an increasing number of leaflets lacerated or removed with TAVR, the average sinus and neosinus velocities increased from 25% to 70% of SAVR flow (100%). Diastolic velocities were substantially augmented by leaflet laceration. Also, the shorter frame of the SAVR led to higher flow velocities compared with the longer frame of the TAVR, even after complete leaflet removal.<br /><b>Conclusions</b><br />Leaflet laceration augmented TAVR native and neosinus flow fields, approaching that of SAVR. These findings may have potential clinical implications for the use of single or multiple leaflet lacerations to reduce leaflet thrombosis and thus potentially improve TAVR durability.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 11 Mar 2023; epub ahead of print</small></div>

<div><h4>Refining the thoracic surgical oncology regionalization standards for esophageal surgery in Ontario, Canada: Moving from good to better.</h4><i>Wright FC, Milkovich J, Hunter A, Darling G, Irish J</i><br /><b>Background</b><br />The consolidation of surgical practices has been suggested to improve patient outcomes for complex surgeries. In 2005, Ontario Health-Cancer Care Ontario released the Thoracic Surgical Oncology Standards to facilitate the regionalization process at thoracic centers in Ontario, Canada. This work describes the quality-improvement process involved in updating the minimum surgical volume and supporting requirement recommendations for thoracic centers to further optimize patient care for esophageal cancer.<br /><b>Methods</b><br />We conducted a literature review to identify and synthesize evidence informing the volume-outcome relationship related to esophagectomy. The results of this review and esophageal cancer surgery common indicators (reoperation rate, unplanned visit rate, 30-day and 90-day mortality) from Ontario\'s Surgical Quality Indicator Report were presented and reviewed by a Thoracic Esophageal Standards Expert Panel and Surgical Oncology Program Leads at Ontario Health-Cancer Care Ontario. Hospital outliers were identified, and a subgroup analysis was conducted to determine the most appropriate minimum surgical volume threshold based on 30- and 90-day mortality rates data from the last 3 fiscal years.<br /><b>Results</b><br />Based on the finding that a significant decrease in mortality occurred at 12 to 15 esophagectomies per year, the Thoracic Esophageal Standards Expert Panel reached a consensus that thoracic centers should perform a minimum of 15 esophagectomies per year. The panel also recommended that any center performing esophagectomies have at least 3 thoracic surgeons to ensure continuity in clinical care.<br /><b>Conclusions</b><br />We have described the process involved in updating the provincial minimum volume threshold and the appropriate support services for esophageal cancer surgery in Ontario.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 10 Mar 2023; epub ahead of print</small></div>

<div><h4>Repeat pulmonary thromboendarterectomy outcomes: A 15-year single-center retrospective review.</h4><i>Astashchanka A, Kerr KM, Yang JZ, Bautista A, ... Madani MM, Fernandes TM</i><br /><b>Objective</b><br />Chronic thromboembolic pulmonary hypertension is potentially curable via pulmonary thromboendarterectomy. A minority of patients experience recurrence of their symptoms and are eligible for repeat pulmonary thromboendarterectomy. However, little data exist regarding risk factors and outcomes for this patient population.<br /><b>Methods</b><br />We performed a retrospective review of the University of California San Diego chronic thromboembolic pulmonary hypertension quality improvement database, including all patients who underwent pulmonary thromboendarterectomy from December 2005 to December 2020. Of the 2019 cases performed during this period, 46 were repeat pulmonary thromboendarterectomy procedures. Demographics, preoperative and postoperative hemodynamics, and surgical complications were compared between the repeat pulmonary thromboendarterectomy group and 1008 first pulmonary thromboendarterectomy group.<br /><b>Results</b><br />Repeat pulmonary thromboendarterectomy recipients were more likely to be younger, to have an identified hypercoagulable state, and to have higher preoperative right atrial pressure. Etiologies of recurrent disease include incomplete initial endarterectomy, discontinuation of anticoagulation (noncompliance or for medical reasons), and anticoagulation treatment failure. Patients who received repeat pulmonary thromboendarterectomy had significant hemodynamic improvement, but less pronounced compared with patients who received first pulmonary thromboendarterectomy. Repeat pulmonary thromboendarterectomy was associated with an increased risk of postoperative bleeding, reperfusion lung injury, residual pulmonary hypertension, and increased ventilator, intensive care unit, and hospital days. However, hospital mortality was similar between the groups (2.2% vs 1.9%).<br /><b>Conclusions</b><br />This is the largest reported series of repeat pulmonary thromboendarterectomy surgery. Despite an increase in postoperative complications, this study demonstrates that repeat pulmonary thromboendarterectomy surgery can result in significant hemodynamic improvement with acceptable surgical mortality in an experienced center.<br /><br />Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 09 Mar 2023; epub ahead of print</small></div>

<div><h4>Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair.</h4><i>Svensson LG, Rosinski BF, Miletic K, Hodges K, ... Roselli EE, Blackstone EH</i><br /><b>Objective</b><br />The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair.<br /><b>Methods</b><br />From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes.<br /><b>Results</b><br />Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16).<br /><b>Conclusions</b><br />Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.<br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 03 Mar 2023; epub ahead of print</small></div>

<div><h4>Pafolacianine for intraoperative molecular imaging of cancer in the lung: The ELUCIDATE trial.</h4><i>Sarkaria IS, Martin LW, Rice DC, Blackmon SH, ... Singhal S, ELUCIDATE Study Group</i><br /><b>Objective</b><br />The study objective was to determine the clinical utility of pafolacianine, a folate receptor-targeted fluorescent agent, in revealing by intraoperative molecular imaging folate receptor α positive cancers in the lung and narrow surgical margins that may otherwise be undetected with conventional visualization.<br /><b>Methods</b><br />In this Phase 3, 12-center trial, 112 patients with suspected or biopsy-confirmed cancer in the lung scheduled for sublobar pulmonary resection were administered intravenous pafolacianine within 24 hours before surgery. Participants were randomly assigned to surgery with or without intraoperative molecular imaging (10:1 ratio). The primary end point was the proportion of participants with a clinically significant event, reflecting a meaningful change in the surgical operation.<br /><b>Results</b><br />No drug-related serious adverse events occurred. One or more clinically significant event occurred in 53% of evaluated participants compared with a prespecified limit of 10% (P < .0001). In 38 participants, at least 1 event was a margin 10 mm or less from the resected primary nodule (38%, 95% confidence interval, 28.5-48.3), 32 being confirmed by histopathology. In 19 subjects (19%, 95% confidence interval, 11.8-28.1), intraoperative molecular imaging located the primary nodule that the surgeon could not locate with white light and palpation. Intraoperative molecular imaging revealed 10 occult synchronous malignant lesions in 8 subjects (8%, 95% confidence interval, 3.5-15.2) undetected using white light. Most (73%) intraoperative molecular imaging-discovered synchronous malignant lesions were outside the planned resection field. A change in the overall scope of surgical procedure occurred for 29 of the subjects (22 increase, 7 decrease).<br /><b>Conclusions</b><br />Intraoperative molecular imaging with pafolacianine improves surgical outcomes by identifying occult tumors and close surgical margins.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 03 Mar 2023; epub ahead of print</small></div>