Aim of the study was to report the long-term results of the clover and edge-to-edge repair for complex tricuspid regurgitation(TR). This was a single-center observational study. A competing risks proportional-hazards regression model, following the Fine-Gray model, was performed to analyze the time to TR≥2+, considering death as a competing risk. Hundred forty-five consecutive patients (female 57%) with severe or moderately-severe tricuspid regurgitation due to leaflets prolapse/flail(115 pts), tethering(27 pts) or mixed(3 pts) lesions underwent clover(110 pts) or edge-to-edge repair(35 pts). TR etiology was degenerative in 75% of cases, post-traumatic in 8% and secondary to dilated cardiomyopathy in 17%. Ring(64%) or suture(31%) annuloplasty was performed in 95% of patients. Concomitant procedures (mainly mitral surgery) were performed in 80% of cases. Hospital death was 5.5%. Follow-up was 98% complete, median 15[14-17] years. The 16-years overall survival was 56±5%. Previous cardiac surgery(HR 2.83, 95%CI 1.15-6.93, P=0.023) and right ventricle dysfunction(HR 2.24, 95%CI 1.01-4.95, P= 0.046) were identified as predictors of death. The 16-years Cumulative incidence function(CIF) of cardiac death with non-cardiac death as competing risk was 19.6% and previous cardiac surgery(HR 3.44, 95%CI 1.23-9.65, P=0.019) was detected as the only predictor of the event. At 16-years, CIF of TR≥2+ with death as competing risk was 23.8%. Particularly, TR≥3+ was detected in 4 patients(3%). When tricuspid regurgitation could not be treated by annuloplasty alone, concomitant leaflet repair with the clover/edge-to-edge technique effectively restored valve competence with very satisfactory long-term results and low rate of moderate or greater TR recurrence.

To provide patients and surgeons with clinically relevant information, the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) was queried to develop a risk model for isolated tricuspid valve (TV) operations. All patients in the STS-ACSD undergoing isolated TV repair or replacement (N=13,587; age 48.3±18.4 years) were identified (7/2017-6/2023). Multivariable logistic regression accounting for TV replacement versus repair was used to model eight operative outcomes: mortality, morbidity and/or mortality, stroke, renal failure, reoperation, prolonged ventilation, short and prolonged hospital stay. Model discrimination (C-statistic) and calibration were assessed using 9-fold cross-validation. The isolated TV study population included 41.1% repairs (N=5,583; age 52.6±18.1 years) and 58.9% replacements (N=8,004; age 45.3±18.0 years). Overall predicted risk of operative mortality was 5.6%, similar in repairs and replacements (5.5% and 5.7%, respectively); as was the predicted risk of composite morbidity and mortality (28.2% and 26.8%). Replacements were generally younger patients with a higher endocarditis prevalence than repairs (45.7% vs. 21.1%). The model yielded a C-statistic of 0.81 for mortality and 0.76 for the composite of morbidity and mortality, with excellent observed-to-expected calibration that was comparable in all sub-cohorts and predicted risk decile groups. A new STS risk model has been developed for isolated TV surgery. The current mortality of isolated TV operations is lower than previously observed. This risk prediction model and these contemporary outcomes provide a new benchmark for current and future isolated TV interventions.

Aggressive resection/exclusion of the primary entry in the descending aorta remains controversial in older patients with acute type A aortic dissection (ATAAD). We investigated the effect of residual primary entry in the descending aorta in younger and older groups. Patients with ATAAD who underwent emergency surgery (n=1103) were divided into younger (< 70 years; n=681) and older (≥ 70 years; n=422) cohorts. Each cohort was further divided into groups with or without residual primary entry in the descending aorta. After propensity score matching, 179 and 71 matched pairs were obtained in the younger and older cohorts, respectively. Surgical outcomes were compared between the residual and non-residual groups in each age cohort. In the younger cohort, the cumulative incidence rate of distal aortic events was significantly higher in the residual than in the non-residual group (10-year: 35 [95% CI, 27-44] % vs. 22 [15-31] %, P=.001). However, in the older group, residual or non-residual primary entry did not affect the rates (10-year:11 [5-20] % vs. 9 [4-17] %, P=.75). Multivariate analysis identified age < 70 years (P<.001; HR, 2.188; 95% CI, 1.493, 3.205) and residual primary entry at the descending aorta (P<.001; HR, 2.142; 95% CI, 1.559-2.943) as significant predictors for distal aortic events. Aggressive resection/exclusion of the primary entry in the descending aorta should be considered for patients aged < 70 years to avoid distal aortic events; however, it might not always be appropriate for the older patients ≥ 70 years.

Limited data exist on the long-term outcomes of transcatheter aortic valve insertion (TAVI) in nonagenarian patients. The purpose of this study is to investigate the relationship between patient baseline comorbidity and frailty on the long-term outcome of the nonagenarian population. Retrospective analysis of 187 consecutive nonagenarian patients who underwent TAVI from 2009 to 2020. Multivariable models were utilized to analyze the association between basleline patient and frailty variables and mortality, stroke, and repeat hospitalization. Long-term survival was compared to an age- and sex-matched US population. The median STS-predicted risk of mortality (STS-PROM) was 10% (IQR, 7-17%). Frailty was met in 72% of patients based on the five-meter walk test, 13% based on KCCQ-12 score, 12% based on KATZ activities of daily living, and 8% based on serum albumin levels. Procedure-related mortality occured in 3 (2%) patients and stroke in 8 (4%). The median duration of follow-up was 3.4 years. Outcomes included death in 150 (80%) patients, stroke in 15, and repeat hospitalization in 114. Multivariable analysis identified no association between any of the baseline patient variables with mortality, stroke, repeat hospitalization, or the combined outcomes (all P>0.05). One- and five-year survival rates in TAVI-treated nonagenarians were similar to age- and sex-matched controls (P=0.27). Long-term death or stroke is independent of STS-PROM and frailty risk variables in this nonagenarian patient population who received TAVI. Furthermore, survival is similar to age- and sex-matched controls.

Sublobar resection offers non-inferior survival vs. lobectomy for ≤2cm NSCLC and is commonly employed for subsolid tumors. While data exists for solid tumors, the minimum adequate margin of resection for subsolid adenocarcinomas remains unclear. Retrospective review of 1101 adenocarcinoma resections at our institution, 2006-2022. tumors≤3cm with ≥10% radiographic ground glass, excised by sublobar resection. positive nodes, positive or unreported margin. The primary outcome was rate of local recurrence(LR) at multiple thresholds of margin distance. Relationship between margin distance and solid-component size was also explored. 194 patients met inclusion criteria. Median(IQR) tumor diameter and margin distance were 12(9-17)mm and 10(5-17)mm, respectively. Median follow-up was 42.5 months. There was a progressive increase in LR with diminishing margin (0.1cm decrements) from 1.5cm to 0.5cm. The difference in the rate of LR between "over"(n=143) and "under"(n=51) was most significant at 0.5cm [8/51(15.7%) vs. 6/143(4.2%),p=0.01] but did not reach α adjusted for multiple comparisons. On Cox regression for LR-free survival (LRFS), margin ≤0.5cm(p=0.19) and %solid component (p=0.14) trended to significance. Combining these using margin-distance-to-solid-component-size ratio, a ratio≤1 did show a significantly higher rate of local recurrence [7(14.3%) vs. 2(2.0%),p=0.009]. Treatment of local recurrences provided at least intermediate-term survival in 87% of recurrences (median post-recurrence follow-up 44 months). During sublobar resection of subsolid lung adenocarcinomas, margin-to-solid-component-size ratio>1.0 appears to be a more reliable factor than margin distance alone to minimize local recurrence. Local recurrence, however, may not impact survival in patients with subsolid adenocarcinomas if timely treatment is administered.

We sought to characterize the association between venovenous extracorporeal membrane oxygenation (VV-ECMO) bridging duration and outcomes in patients listed for lung transplantation. A retrospective observational study was conducted using the Organ Procurement and Transplantation Network (OPTN) database to identify adults (≥18 years old) who were listed for lung transplantation between 2016-2020 and who were bridged with VV-ECMO. Patients were then stratified into groups, determined by risk inflection points, depending on the amount of time spent on pre-transplant ECMO: Group 1 (≤5 days), Group 2 (6-10 days), Group 3 (11-20 days), and Group 4 (>20 days). Waitlist survival between groups was analyzed using Fine-Gray competing risk models. Post-transplant survival was compared using Cox regression. Of 566 eligible VV-ECMO bridge-to-lung-transplant patients (median age=54, 49% male), 174 (31%), 124 (22%), 130 (23%), and 138 (24%) were categorized as Groups 1, 2, 3, and 4, respectively. Overall, median duration of VV-ECMO was 10 days (range=1-211) and 178 patients (31%) died on the waitlist. In the Fine-Gray model, compared to Group 1, patients bridged with longer ECMO durations in Groups 2 (SHR=2.95, 95%CI: 1.63-5.35), 3 (SHR=3.96, 95%CI: 2.36-6.63), and 4 (SHR=4.33, 95%CI: 2.59-7.22, all p<0.001), were more likely to die on the waitlist. Of 388 patients receiving a transplant, pre-transplant ECMO duration was not associated with one-year survival in Cox regression. Prolonged ECMO bridging duration was associated with worse waitlist mortality but did not impact post-lung transplant survival. Prioritization of very early transplantation may improve waitlist outcomes in this population.