Society Of Thoracic Surgeons Research Articles

A gift of life, not immortality: Evaluation of a strategy of heart transplant listing in the older patient with advanced heart failure

Patients 65 years of age or older represent the fastest-growing demographic group added to the U.S. heart transplant (HT) list. While post-HT outcomes appear acceptable, immortal time bias is introduced if adverse outcomes that occur while waiting for HT are not considered. Recent durable left ventricular assist device (dLVAD) technological innovations have engendered the question of whether this patient subgroup would achieve equivalent survival from a strategy of primary dLVAD implant as opposed to HT listing. We identified adults ≥65 years of age listed for HT between 2018-2021, excluding persons with dLVAD support and/or multi-organ listing. Among 1176 patients, 2-year survival from HT listing was 78.4 ± 1.2%, similar to the 71% to 75% reported in The Society of Thoracic Surgeons (STS) Intermacs National Database for older adults. Linkage of the Scientific Registry of Transplant Recipients with STS Intermacs would enable comparative effectiveness analyses of surgical heart failure therapeutic strategies in high-risk patient cohorts.

Abstract 4138248: Outcomes of Patients with Radiation-Associated Cardiac Disease Undergoing Cardiothoracic Surgery: Development of a Disease Specific Risk Score

Background: Radiation-associated cardiac disease (RACD) has significant long-term mortality and morbidity, often requiring cardiac surgery(CS). Hypothesis: We sought to study factors associated with longer-term survival in RACD patients and develop a specific risk score associated with 5-year survival following CS. Methods: This was an observational cohort study of 351 patients with documented RACD (252 [72%] had mantle radiation for lymphoma at a mean of 18 years prior), who underwent CS at a tertiary care center between 1991-2018. Clinical characteristics were collected, and Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality. Multivariable analysis for 5-year mortality was performed using age, sex, history of lymphoma, New York Heart Association class, prior cardiac surgery, atrial fibrillation, constriction, chronic pulmonary disease, serum creatinine, left ventricular ejection fraction, right ventricular systolic pressure and valvular surgery(aortic, mitral or tricuspid). Results: Clinical characteristics are shown in Figure 1. Mean follow-up was 6.2±4.6 years&5-year mortality occurred in 123 (35%) patients (7 [2%] in-hospital deaths). Cox 5-year survival analysis results are shown in Figure 2A. A receiver operator curve analysis for 5-year mortality showed an area under curve of 0.70 (95% confidence interval 0.64-76, p<0.001). Subsequently, a 5-year risk score (0-7 points) was generated (Figure 2 A); with an increasing risk of mortality at 5 years, based on increasing risk score (Figure 2C). Cardiac reoperation was not associated with worse outcomes. Conclusion: RACD patients undergoing CTS have a high rate of 5-year mortality, despite a low baseline STS score&perioperative mortality. A novel RACD-specific risk score (incorporating higher age, abnormal renal/pulmonary, constrictive pericarditis&need for concomitant mitral valve surgery) provides good discrimination for 5-year survival&could be used for shared-decision making.

Multi-Institutional Model to Predict Intensive Care Unit Length of Stay after Cardiac Surgery

Intensive care unit length of stay (ICU LOS) accounts for a large percent of inpatient cost following cardiac surgery. The Society of Thoracic Surgeons (STS) risk calculator predicts total LOS but does not discriminate between ICU and non-ICU time. We sought to develop a predictive model of prolonged ICU LOS. Adult patients undergoing STS index operations within a regional collaborative (2014-2021) were included. Prolonged ICU LOS was defined as ICU care for ≥72 hours postoperatively. A logistic regression model was utilized to develop a prediction model for the prolonged ICU LOS with pre-specified risk factors identified from our previous single center study. Internal prediction model validation was determined by bootstrapping resampling method. The prediction model performance was assessed by measures of discrimination and calibration. We identified 37,519 patients that met inclusion criteria with 11,801 (31.5%) patients experiencing prolonged ICU stay. From the logistic regression model, there were significant associations between prolonged ICU LOS and all pre-specified factors except sleep apnea (all p<0.05). MELD, preoperative intra-aortic balloon pump use, and procedure types were the most significant predictors of prolonged ICU LOS (all p<0.0001). Our prediction model had not only a good discrimination power (bootstrapped-corrected C-index=0.71) but also excellent calibration (bootstrapped-corrected mean absolute error=0.005). Prolonged ICU stay following cardiac surgery can be predicted with good predictive accuracy utilizing preoperative data and may aid in patient counseling and resource allocation. Through use of a state-wide database, the application of this model may extend to other practices.

Association of TRI-SCORE with clinical outcomes after percutaneous tricuspid annuloplasty

Abstract Background Significant tricuspid regurgitation (TR) has been associated with excess mortality and heart failure. Functional TR is associated to progressive right ventricular remodeling and dysfunction, leading to comorbidities which elevate the perioperative mortality of isolated tricuspid regurgitation surgery, with an in-hospital mortality between 6-10% according to series. Transcatheter tricuspid annuloplasty is a promising therapeutic alternative in patients with high surgical risk. Appropriate risk stratification and patient selection is essential to ensure benefits of this intervention. European System for Cardiac Operative Risk Evaluation (EUROSCORE) II and the Society of Thoracic Surgeons (STS) score are widely spread in-hospital mortality risk scores in valvular surgery. TRI-SCORE is focused on isolated TR surgery; nevertheless, application of these scores to transcatheter annuloplasty has not been specifically studied yet. Purpose To analyze the utility of surgical scores (EUROSCORE-II, STS and TRISCORE) to predict all-cause mortality in patients undergoing transcatheter tricuspid annuloplasty. Methods A cohort of 49 patients with significant TR was followed up prospectively after the transcatheter tricuspid annuloplasty with Cardioband between 2019 and January 2024 (mean follow-up 18,43 ± 10,95 months). Every score was evaluated in all patients. According to the TRI-SCORE –– 6 points was the 75-percentile and taken as cutoff value –– we divided the cohort in two groups: a low score group (≤6 points) and a high score group (&amp;gt;6 points). Survival was analyzed in the whole cohort and in both subgroups. The curves are depicted using Kaplan-Meier method and were compared using log rank test. Results The study included 49 patients, with mean age of 77,6 ± 7,67 years, 77,6% being women. All the patients had a secondary etiology of TR and 46,9% massive or torrential TR before the intervention. 49% had previous left heart surgery. The median surgical risk values are represented in Table 1. All-cause mortality during follow-up occurred in 9 patients (18,3%). Survival analysis based on EUROSCORE II and STS did not find statically significant association (Table 1). TRI-SCORE had a hazard ratio (HR) of 1,59, also without statically significant association (CI 0.93 – 2.71; p 0.089). Survival analysis in high score group found an increased risk of all-cause mortality (HR 8.5; p 0.025). According to our findings TRI-SCORE &amp;gt; 6 before the procedure confers significant risk of all-cause death (log rank p = 0.009). Figure 1. Conclusions Transcatheter tricuspid annuloplasty is a promising therapy for patients with significant TR regurgitation who are at high surgical risk. According to our findings, TRI-SCORE is an appropriate scoring model to predict all-cause mortality after percutaneous annuloplasty with band. It is not so for other surgical risk scores. Extended follow-up and broader experienced are needed to corroborate these results.Surgical scores: median and mortalitySurvival curves TRI-SCORE

Comparison of mortality scores performance in transcatheter aortic valve replacement: suiting up to percutaneous intervention

Abstract Introduction As transcatheter aortic valve replacement (TAVR) is increasingly relevant for patients with severe symptomatic aortic stenosis, having a reliable procedure specific risk-prediction tool is paramount to provide high-quality care. Surgical scores as the EuroScore II and the Society of Thoracic Surgeons (STS) score II have been widely used to identify patients with high surgical risk in whom percutaneous treatment might be more favorable. However, current literature lacks a consensual specific predictive model for short-term and mid-term prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). Purpose We aimed to access short and midterm (30 days and one year) mortality and to access the ability of a directly adapted score in estimating mortality in a real-world population. Methods We conducted a retrospective observational study in patients who implanted TAVR in a single center. Surgical mortality scores – EUROSCORE II and STS score II – and adapted score Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) transcatheter valve therapy (TVT) score were used to estimate mortality. Predictive abilities of these three scores were compared using area under the receiver operating characteristics (ROC) curve for 30-day and one year mortality. Results From January 2018 to December 2021, 416 patients were submitted to TAVR procedure in our center. The mean age was 83+-6 years old and 229 (55%) were female. 94% had hypertension, 80% dyslipidemia, 40% diabetes mellitus, 35% coronary artery disease, 32% chronic kidney disease. Mean ejection fraction was 56%. During a mean follow-up (FUP) of 816 ± 492 days, 30-day mortality was 1,7% and after 1 year mortality rate was 12,2% (higher than reported in PARTNER 3 trial, 8,5%). The Mean EuroSCORE was 3,4±3,2, mean STS-II 3,9±1,8 and mean value for STS/ACC-TVT score was 3,55±1,34. ROC curve analysis showed a significantly higher discriminative power of STS/ACC-TVT (AUC 0,749, 95% CI 0,681-0,818) compared with surgical scores (p=0,001) – figure 1. We also divided population into quartiles and compared the mortality rate at 30 days and 1 year in each quartile using either STSII or STS/ACC-TVT; As can be seen in figure 2, mortality rates correlated better with the STS/ACC-TVT score than with the STS score. Conclusion A score adapted to a TAVI population showed better predictive capacity than traditional surgical scores. Less preponderance of previous surgical status, relevance of access site and more adapted weight of age might explain the best performance of STS/ACC-TVT score. Surgical scores are helpful in choosing treatment option, but adapted scores are better to predict pos-TAVR mortality.

Incidence of aortic valve reintervention in patients with aortic stenosis undergoing TAVI vs SAVR: A systematic review and meta-analysis of randomised controlled trials

Abstract Introduction Transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) are two established treatments for severe aortic stenosis (AS). The relative comparison between TAVI and SAVR for recurrent aortic valve interventions is not well defined. Purpose We aimed to perform a systematic review and meta-analysis comparing the incidence of aortic valve reintervention in patients undergoing TAVI versus SAVR. Methods MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials (RCT) that compared TAVI with SAVR for the treatment of AS reporting the occurrence of aortic valve reinterventions. We also performed a subgroup analysis of different types of TAVI prosthesis. We performed a meta-regression to evaluate the effect of age and Society of Thoracic Surgeons (STS) risk score in the outcome of interest. Statistical analysis was performed using RevMan 5.4.1 and RStudio 2023.12.1. Heterogeneity was assessed with I2 statistics. Results We included 8 RCTs with 8,698 patients, of whom 4,443 (51%) underwent TAVI. Mean follow-up ranged from 1 to 10 years. Aortic valve reintervention was significantly more common in patients treated with TAVI compared with SAVR (RR 1.89; 95%CI 1.24-2.88; p = 0.003). In a subgroup analysis stratified by balloon-expandable or self-expandable valves, there were no significant subgroup differences in their respective comparisons with TAVR (p = 0.20). In meta-regression analysis, older age (p = 0.008) and higher STS score (p = 0.009) were significantly associated with a higher incidence of aortic valve reinterventions with TAVI relative to SAVR. Conclusion In patients who undergo aortic valve replacement, TAVI is associated with a significantly higher incidence of aortic valve reinterventions relative to SAVR, particularly in populations with older age or higher STS score.

One-year outcomes of transcatheter mitral valve replacement in patients with severe mitral regurgitation

Abstract Background Mitral valve regurgitation (MR) is a prevalent valvular heart disease, and a subset of patients face challenges in undergoing surgical treatment. Transcatheter mitral valve replacement (TMVR) has emerged as a viable option for selected patients with severe MR deemed unsuitable for traditional valve surgery. Purpose This study aims to evaluate the feasibility, safety, durability, and clinical outcomes of a novel transapical mitral valve system (MitraFix valve) in treating moderate to severe MR patients. Methods The early feasibility study of the MitraFix TMVR transapical system is a multicenter, prospective, nonrandomized study. All patients underwent evaluation by a multidisciplinary heart team and were deemed suitable for mitral valve intervention. Clinical events were adjudicated by an independent clinical events committee. Results From June 2021 to July 2022, 10 patients (mean age: 71.2 ± 7.4 years, 40% male) were enrolled. The mean Society of Thoracic Surgeons(STS) predicted risk of mortality was 7.5 ± 2.7%. All implants were successful, with a mean operational time of 45.2 ± 25.9 min. One patient was converted to open cardiac surgery after successfully implanting the valve due to persistent apical bleeding. At 1-year follow-up, all-cause mortality was 20%, with a cardiovascular mortality at 10.0%. Among survival patients, 87.5% of surviving patients had MR ≤1+ and 75% patients were in NYHA functional class I or II at 1 year. The overall KCCQ score significantly increased from 55.8 (42.9, 72.9) points at baseline to 77.5 (73.7, 88.6) points at 1-year follow up (P = 0.012). Left ventricular ejection fraction showed no significant change from basline (51.5%) to 1 year (50.0%) (P=0.799). No evidence of mitral stenosis or left ventricular outflow tract (LVOT) obstruction was observed. Conclusions The MitraFix TMVR transapical system demonstrated excellent valve function, low mortality, sustained MR elimination and clinical improvement up to one year in this study. Further studies, encompassing a larger cohort of patients and an extended follow-up duration, are needed to confirm these findings.Change in MR and NYHA functional classChange in Quality-of-Life Assessment

Trends in Transcatheter Aortic Valve Replacement Outcomes

Although transcatheter aortic valve replacement (TAVR) outcomes in the US have improved substantially since 2011, it is unknown whether these trends have continued since 2019. To examine changes in risk-adjusted TAVR outcomes from 2019 to 2022 and to examine any noteworthy trends over time. This cohort study examined data from patients with severe aortic stenosis treated with TAVR at 786 US hospitals between January 1, 2019, and March 31, 2022, included in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) Transcatheter Valve Therapies (TVT) Registry. Patients who underwent TAVR. The primary outcome was 30-day mortality, and the secondary outcomes were in-hospital mortality and 30-day composite adverse events. To understand factors explaining these trends, a series of logistic regression models was constructed for each outcome, with time as the primary explanatory variable. After adjusting for changing patent characteristics and procedural factors, a series of exploratory analyses was performed to examine the extent to which these findings could be explained by several plausible hypotheses. This study's analytic cohort included a total of 210 495 patients. Median (IQR) patient age was 79 (73-85) years, and 91 313 patients (43.4%) were female. Median (IQR) STS predicted risk of mortality (PROM) was 3.3% (2.0%-5.3%). There were no significant changes in unadjusted 30-day mortality from quarter 1 of 2019 (2.4%) to the end of quarter 1 of 2022 (2.2%) (P for trend = .10), with an unadjusted odds ratio (OR) for time of 0.98 per year (95% CI, 0.94-1.01). After adjusting for patient characteristics, the OR increased to 1.05 per year (95% CI, 1.02-1.08), which increased further after adjusting for procedural characteristics to 1.09 per year (95% CI, 1.05-1.13). In exploratory analyses, there were no meaningful changes in the adjusted odds of death after excluding sites that entered the STS/ACC TVT Registry in 2019 or later (OR, 1.09; 95% CI, 1.05-1.13), low-volume sites (OR, 1.09; 95% CI, 1.06-1.13), low-risk patients (OR, 1.11; 95% CI, 1.07-1.15), patients with a bicuspid aortic valve (OR, 1.09; 95% CI, 1.05-1.13), in-hospital deaths (OR, 1.08; 95% CI, 1.03-1.14), or patients who experienced a major vascular complication (OR, 1.09; 95% CI, 1.05-1.12). In this observational cohort study performing a national analysis of outcomes after TAVR, it was found that risk-adjusted 30-day mortality increased modestly from January 2019 to March 2022. However, no site-level, patient-related, or process-related factors were identified that could explain these findings. Although the absolute increase in risk-adjusted mortality during the study period was relatively small, these findings warrant continued surveillance.

Acute Kidney Injury after Isolated Coronary Bypass Surgery

AbstractAcute kidney injury (AKI) is among the most serious of the common postoperative complications of cardiac surgeries, which can increase the short- and long-term morbidity and mortality of patients. This study aimed to examine possible risk factors that lead to AKI. We sought to compare our AKI rates to national averages in coronary artery bypass grafting (CABG) reported by the Society of Thoracic Surgeons (STS). We reviewed our institution's data for renal failure in CABG procedures performed between January 1, 2020, and June 30, 2023. From the database, we identified 1,068 CABG patients and reviewed demographics, nonmodifiable conditions, and modifiable risk factors. The STS database uses the Risk, Injury, Failure, Loss, and End-stage renal disease definition for renal failure. Of our patient sample, 14 (1.3%) experienced renal failure. The national rate for AKI after isolated CABG was 1.9% in 2023. Chronic lung disease was a risk factor for AKI development. The mean perfusion, cross-clamp, ventilator times, and hospital stay increased in AKI patients. All patients who suffered from AKI had undergone perioperative blood transfusion. Our single-center experience with renal failure is slightly better than the national average. In our population, chronic lung disease and lower preoperative ejection fractions were associated with increased rates of AKI. Modifiable risk factors in our population included perioperative blood transfusion and increased perfusion/cross-clamp times. Lastly, AKI patients spent longer time on ventilators, increased lengths of stay, and increased postoperative mortality.

Early stroke following durable left ventricular assist device (LVAD) implantation: An analysis of the Society of Thoracic Surgeons Intermacs National Database

BackgroundStroke remains a devastating complication of durable left ventricular assist device (LVAD) therapy. This study evaluated the incidence and risk factors for early stroke within 7 days following LVAD implantation investigating both traditional pre-implant and new intraoperative variables collected by The Society of Thoracic Surgeons (STS) Intermacs National Database. MethodsSTS Intermacs was queried for patients undergoing implantation of a fully magnetically levitated centrifugal LVAD between 11/25/2020 and 6/30/2023. STS Intermacs stroke definitions were used to identify patients who suffered a stroke within the first 7 postoperative days (POD). A multivariable logistic regression model was created to generate adjusted odd ratios (OR) for variables associated with early stroke. ResultsAmong 6950 patients in the study cohort, 5.9% (413/6950) developed a stroke after a median follow-up of 11 months, with 50% (205/413) of strokes occurring within 7 days after LVAD implantation. Of the strokes occurring during POD 0-7, 70% (144/205) occurred on POD 0-2. By multivariable analysis, the following factors were associated with early stroke: older age (70 vs. 50; OR 1.4, P=0.0129), white race (OR 1.5, P=0.0078), pre-implant temporary MCS bridge (temporary LVAD only: OR 1.6, ECMO only: OR 1.7, combination of both devices: OR 3.3; P=0.0001) and presence of an unremoved left atrial clot (OR 8.0, P<0.0001). ConclusionA significant proportion of strokes occur within the first 7 days following LVAD implantation, particularly within the first 2 days. In addition to pre-implant variables, we identified modifiable intraoperative factors associated with stroke that provide an opportunity for further risk mitigation and improvement in quality of care.

The Society of Thoracic Surgeons Intermacs 2024 Annual Report: Focus on Outcomes in Younger Patients

The 15th Annual Report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) includes 29,634 continuous-flow left ventricular assist devices (LVAD) from the 10-year period between 2014 through 2024. The outcomes reported here demonstrate continued improved survival in the current era of fully magnetically levitated (Mag-Lev) devices, with a significantly higher 1-year (85.7% versus 78.4%) and 5-year (59.7% versus 43.7%) survival than those receiving non-Mag-Lev devices. Mag-Lev recipients are experiencing a lower incidence of adverse events, including freedom from GI bleeding (72.6%), device malfunction (82.9%) and stroke (86.7%) at 5 years. Additionally, a focus on a subgroup of patients less than 50 years of age have demonstrated superior outcomes in both survival (91.6% survival at 1 year and 72.6% survival at 5 years) and decreased incidence of adverse events compared to older recipients. This younger cohort also demonstrated more tolerance to the characteristics of sex, race, ethnicity and psychosocial indicators that are associated with worse outcomes following heart transplantation (HT). Based upon these data, a potential net prolongation of life may be realized by considering prolonged LVAD support prior to HT in this population. These analyses provide preliminary data that could positively influence adoption of LVAD technology in groups previously not seen as candidates for this therapy, while providing a more responsible donor allocation strategy for advanced heart failure patients.

Harmonizing guidelines and other clinical practice documents: A joint comprehensive methodology manual by the American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and Society of Thoracic Surgeons (STS).

Harmonizing guidelines and other clinical practice documents: A joint comprehensive methodology manual by the American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and Society of Thoracic Surgeons (STS).

Association between triglyceride-glucose index and all-cause mortality in patients underwent transcatheter aortic valve replacement

BackgroundsThe prognosis of the triglyceride-glucose (TyG) index, a validated surrogate marker for insulin resistance, in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains unknown.MethodsThis study consecutively enrolled patients diagnosed with severe AS who underwent TAVR in a Chinese tertiary hospital from March 2013 to September 2023. Participants were stratified based on the TyG index cut-off value. Cox proportional hazards regression models were utilized to explore the association between the TyG index and all-cause mortality, including an assessment of interactions between the TyG index and various covariates on mortality outcomes.ResultsAmong 1045 patients (mean age 74.7 years, 58.2% male), there was 134 all-cause mortality, resulting in a crude mortality rate of 64.3 per 1000 person-years. Adjusting for age, sex, body mass index, smoking, hypertension, diabetes mellitus, bicuspid aortic valve, atrial fibrillation, Society of Thoracic Surgeons (STS) score, and left ventricular ejection fraction, a per-unit increase in the TyG index was associated with a 41% higher all-cause mortality risk (HR 1.41, 95% CI 1.03–1.93, p = 0.030). Notably, the relationship between the TyG index and all-cause mortality was significantly modified by age (pinteraction = 0.027), sex (pinteraction = 0.007), hypertension (pinteraction = 0.030), and STS score (pinteraction = 0.002).ConclusionsA higher TyG index is significantly associated with an increased risk of all-cause mortality in AS patients after TAVR. These results underscore the importance of considering the TyG index in the prognostic evaluation of AS patients following TAVR.

Fate of Abstracts Presented at Annual Meetings of The Society of Thoracic Surgeons from 2015 to 2019

Society of Thoracic Surgeons (STS) annual meetings provide opportunities to disseminate cardiothoracic research. We assessed rates of publication of STS abstracts as manuscripts in peer-reviewed journals over five years and determined factors associated with successful publication. The STS "Annual Meeting Archive" was searched online for abstract books from STS annual meetings from 2015-2019. Abstract books were reviewed for information about presented abstracts. A PubMed and Google search was then performed to identify corresponding peer-reviewed journal publications. A total of 1451 abstracts were presented at STS annual meetings from 2015-2019. Overall publication rate of accepted abstracts as manuscripts in peer-reviewed journals was 1097/1451=75.60%. Most published manuscripts were published in The Annals of Thoracic Surgery (750/1097=68.37%). Median duration between abstract presentation and peer-reviewed journal publication was 313[IQR=212.5-458] days. Only 29/1451=2.00% of abstracts won an award, and all 29 of these award-winning abstracts were published as a manuscript. Oral presentation was associated with increased odds of publication compared to poster presentation (OR=1.28[95% CI=1.04-1.71], p=0.021). Median 5-year impact factor of peer-reviewed journals containing these manuscripts was 5.04[IQR=5.04-5.04], and corresponding manuscripts were cited a median of 4[IQR=1-9] times. Overall, 836/1097=76.20% of manuscripts published in peer-reviewed scientific journals had a corresponding North American author. Annual STS meetings are a forum for the presentation of high-quality research. The rate of publication of accepted STS abstracts as manuscripts in peer-reviewed journals is >75%, comparing favorably with national meetings of other surgical societies, and >2/3 of published manuscripts are published in STS's official journal.

Incidence and Prognostic Significance of Silent Coronary Disease in Asymptomatic Patients with Severe Aortic Stenosis.

Background and Objectives: The aim of this study was to estimate the prevalence of silent coronary artery disease (CAD) in asymptomatic patients with severe aortic stenosis (AS) and assess long-term prognosis in terms of major adverse cardiovascular event (MACE)-free survival. Materials and Methods: This was a prospective study conducted at the Clinic for Cardiac Surgery, University Clinical Center of Serbia, in asymptomatic patients with severe AS, normal LVEF and stress test without signs of myocardial ischemia. Adverse cardiovascular events (cardiac death, myocardial infarction and any hospitalization due to heart disease) was monitored during one year of follow up. Results: A total of 116 asymptomatic patients with severe AS were included in the study. The average age was 67.3 ± 9.6 years, and 56.9% of patients were men. The most common cause of AS was degenerative valvular disease (83.5%). The incidence of significant CAD was 30 out of 116 patients (25.9%). The median Society for Thoracic Surgeons (STS) predicted risk of mortality score was 1.62% (25th to 75th percentile: 1.15-2.76%). The overall mean gradient across aortic valve (Pmean) was 52.30 mmHg ± 12.16, and the mean indexed AVA (AVAi) was 0.37 ± 0.09 cm2/m2. The mean LVEF was 68.40% ± 8.01%. Early surgery for aortic valve replacement was performed in 55 patients (55.2%), while 52 (44.8%) patients received conservative treatment. Twenty-two patients (42.3%) in the conservative treatment group underwent surgery during follow up. There were a total of 44 (37.9%) patients with MACE during one year of follow up. Univariate Cox regression analyses identified the following significant risk factors for MACE-free survival: presence of CAD and early conservative treatment (p = 0.004), age (p = 0.003), diabetes mellitus (p = 0.016) and STS score (p = 0.039). According to multivariate analysis, the presence of CAD with early conservative treatment was the most important predictor of MACE-free survival in asymptomatic patients with severe aortic stenosis (p ≤ 0.001). Conclusions: Early surgery for aortic valve replacement in asymptomatic patients with severe AS and concomitant CAD is beneficial for long-term survival.

Sex-related disparities in aortic stenosis from disease awareness to treatment: a state-of-the-art review.

This state-of-the-art review aimed to synthesize evidence from various sex-stratified studies on aortic stenosis (AS), focusing on the difference in clinical presentation, anatomical characteristics, pathophysiology, and management of AS. In comparison to men, women with AS are present at later stages, are older, more symptomatic, frailer, and exhibit higher operative risk [Society of Thoracic Surgeons (STS) score]. Women tend to have smaller aortic valve (AV) areas and left ventricular (LV) outflow tract, leading to lower stroke volumes (SVs) than men and have a higher prevalence of paradoxical, low-flow, low-gradient AS. In women, chronic pressure overload due to AS results in concentric LV remodelling and hypertrophy, characterized by reduced LV cavities, higher filling pressures, lower wall stress, and more diastolic dysfunction. Conversely, men exhibit more dilated eccentric LV remodelling and hypertrophy. AVs in women are less calcified but more fibrotic. Moreover, women are often underdiagnosed, have severity underestimated, and experience delays or receive fewer referrals for AV replacement (AVR). However, women tend to benefit from transcatheter AVR (TAVR) with a long-term survival advantage over men, although the incidence of vascular complications and bleeding events in 30 days after TAVR is higher in women. Surgical AVR (SAVR) in women has high operative risk, is technically demanding and has poorer outcomes with increased mortality at 30 days compared to men. According to the STS score and EuroSCORE, the female sex itself is considered a risk factor for SAVR. Therefore, addressing sex-related disparities in AS and increasing awareness among physicians promises improved diagnosis and treatment, facilitating equitable care and the development of sex-specific personalized medicine.

Patient-Tailored Therapy for Complex Aortic Arch Anatomy: An Evolving Research Field with Custom-Made Solutions.

The treatment of complex aortic pathologies requires specialized techniques and tailored approaches due to each patient's unique anatomical and clinical challenges. The European Association for Cardiothoracic Surgery (EACTS) and the Society of Thoracic Surgeons (STS) new guidelines identify the aorta as the body's 24th organ and reiterate that multidisciplinary aortic teams are recommended for shared decision-making to determine optimal treatment strategies. Patients treated for conditions such as aneurysms, dissections, intramural hematomas, or penetrating aortic ulcers may develop complex forms over time, necessitating careful follow-up and timely corrective actions. Endovascular solutions can be favorable for older patients with complex anatomies and multiple comorbidities. However, when endovascular treatment is not feasible, hybrid treatments or open surgery must be considered if the patient's condition allows it. The risk-benefit ratio of each procedure must be carefully evaluated; choosing the best intervention or deciding not to intervene becomes a critical and challenging decision. At our Cardiac Surgery Center in Verona, a multidisciplinary team with over 20 years of experience in treating complex aortic arch pathologies extensively discussed different cases of complex aortic pathologies treated with endovascular, hybrid, or surgical approaches, emphasizing the importance of considering both anatomical and patient-specific characteristics. The decisions and treatments were often challenging, and unanimity was not always achieved, reflecting the complexity of finding the best solutions.

Aortic Outcome after Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch

ObjectiveTo evaluate outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD). MethodsThis retrospective observational study adhered to the STROBE checklist. All cases of NANB AAD (B 1-2 D) treated at our Institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodelling were analysed. ResultsAmong 519 cases of acute aortic syndrome, n=22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n=16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly two days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7(31.8%) needed emergent operation for risks of impending aortic rupture/retrograde AD extension and 4(26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of FL thrombosis (100% vs 55.5%, p=.033) and a significant positive aortic remodelling in zone 3 (p<.001) and 4 (p=0.038) were reported in operated versus medically managed patients. ConclusionThe best treatment for NANB is not established. We advocate for medical stabilisation with an operative approach that favours open surgery in the acute post dissection period, promotes aortic remodelling and carries acceptable risk in centres where FET is performed routinely.

A clinical comparison of glycol and water-based heater-cooler systems for cardiopulmonary bypass.

While newer heater-cooler technologies using ethylene glycol-based (GB) solutions during cardiothoracic surgery have become commercially available, there is a paucity of clinical data describing their effectiveness during cardiopulmonary bypass (CPB) support. This analysis aimed to compare clinical characteristics and procedural outcomes using water-based (WB) and GB heater-cooler systems. A retrospective analysis was performed on consecutive adult patients undergoing CPB from June to October 2022 comparing WB or GB groups. The primary outcome was a composite of operative death or major morbidity. Secondary endpoints included transfusion requirements on CPB, patient cooling and warming rates, and vasoactive-inotropic scores (VIS) at case completion. P-control charts were used to monitor the weekly incidence of the composite outcome. A sub-analysis was performed to evaluate the primary outcome for cardiac surgery cases indexed by the Society of Thoracic Surgeons (STS). There were 167 patients included for analysis; 87 (52.1%) underwent CPB with a WB system and 80 (47.9%) with a GB system. GB procedure subjects were younger (p = .01), experienced longer CPB times (p = .034), and were more likely to receive thoracic transplant or aortic surgery (p = 0.015). The composite outcome of operative mortality or major morbidity occurred in 29.9% and 24% of the WB and GB groups, respectively (p = .372). P-control charts indicated a weekly mean incidence of 30% during WB practice, which decreased to 24% with GB practice. Among 106 STS-indexed cardiac surgery cases, mean composite outcome incidence decreased from 19% to 6% following our GB transition. Additionally, cooling, and warming rates indexed to patient BSA and VIS at case completion were not significantly different. Our analysis demonstrated a safe transition from WB to GB heater-cooler technologies in our practice. This early analysis suggests that GB heater coolers may be safely adopted to mitigate the risks of nontuberculous mycobacterium infections for cardiac surgical patients.

Contemporary Outcomes and Trends for the Transseptal Mitral Valve-in-Valve Procedure Using Balloon Expandable Transcatheter Valves in the United States.

Previous transcatheter valve therapy registry analyses of transcatheter mitral valve in valve (MViV) replacement of degenerated bioprosthesis reported early experience in the United States. Given recent increases in transseptal MViV volumes and introduction of the SAPIEN 3 Ultra valve, it is important to determine contemporary outcomes for patients undergoing transseptal SAPIEN 3/SAPIEN 3 Ultra MViV replacement. The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy Registry was used to extract data for all patients undergoing transseptal SAPIEN 3/SAPIEN 3 Ultra MViV from 2015 to September 2022. Primary efficacy outcome was 1-year all-cause mortality. Secondary end points included 30-day mortality, functional class, quality of life, and mitral valve performance. Primary safety outcomes were device success and in-hospital complications. A total of 4243 patients with a mean±SD STS score of 9.2±7.7 underwent transseptal MViV at 455 sites. The rate of Mitral Valve Academic Research Consortium technical (96.6%) success was high, and procedural complications were low. All-cause in-hospital, 30-day, and 1-year mortality rates were 3.2%, 4.3%, and 13.4%, respectively. Significant improvements in New York Heart Association class (New York Heart Association I/II, 18% to 87%) and quality of life (Kansas City Cardiomyopathy Questionnaire score, 38 to 78) were noted at 1 year (P<0.0001 for both) after MViV. Upon stratifying by STS scores, it was observed that the low-risk group (STS<4) had a significantly lower in-hospital mortality rate of 0.4%, whereas the intermediate-risk group (STS, 4-8) had an in-hospital mortality rate of 1.9%. From 2015 to 2022, the number of transseptal MViV cases/year increased significantly, whereas procedure times, length of stay, and intensive care unit hours shortened significantly. At the same time, there was a significant trend toward reduced in-hospital (P=0.0005), 30-day (P=0.004), and 1-year mortality rates (P=0.01). This multicenter, prospective study reports excellent procedural outcomes, acceptable 1-year mortality rates, and a significant improvement in quality of life for patients undergoing transseptal MViV in the contemporary era. Patients in the low-risk and intermediate-risk STS score categories had significantly better outcomes compared with those in the high-risk category. MViV is a reasonable therapy for the majority of patients with degenerated bioprosthetic mitral valves, who are anatomical candidates.