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Objective: The use of transcatheter edge-to-edge repair (TEER) is growing substantially, and reintervention after TEER by way of repeat TEER or mitral valve surgery (MVS) is increasing as a result. In this nationally representative study we examined the incidence, characteristics, and outcomes of reintervention after index TEER., Methods: Between July 2013 and November 2017, we reviewed 11,396 patients who underwent index TEER using Medicare beneficiary data. These patients were prospectively tracked and identified as having repeat TEER or MVS. Primary outcomes included 30-day mortality, 30-day readmission, 30-day composite morbidity, and cumulative survival., Results: Among 11,396 patients who underwent TEER, 548 patients (4.8%) required reintervention after a median time interval of 4.5 months. Overall 30-day mortality was 8.6%, 30-day readmission was 20.9%, and 30-day composite morbidity was 48.2%. According to reintervention type, 294 (53.7%) patients underwent repeat TEER, and 254 (46.3%) underwent MVS. Patients who underwent MVS were more likely to be younger and female, but had a similar comorbidity burden compared with the repeat TEER cohort. After adjustment, there were no differences in 30-day mortality (adjusted odds ratio [AOR], 1.26 [95% CI, 0.65-2.45]) or 30-day readmission (AOR, 1.14 [95% CI, 0.72-1.81]). MVS was associated with higher 30-day morbidity (AOR, 4.76 [95% CI, 3.17-7.14]) compared with repeat TEER. Requirement for reintervention was an independent risk factor for long-term mortality in a Cox proportional hazard model (hazard ratio, 3.26 [95% CI, 2.53-4.20])., Conclusions: Reintervention after index TEER is a high-risk procedure that carries a significant mortality burden. This highlights the importance of ensuring procedural success for index TEER to avoid the morbidity of reintervention altogether., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Atrial functional mitral regurgitation (FMR) occurs because of left atrial dilatation or atrial fibrillation in heart failure with preserved left ventricular (LV) function, contrary to ventricular FMR, which occurs because of LV dysfunction. Despite pathophysiological differences, current guidelines do not discriminate between these 2 entities., Methods: From January 2002 to March 2019, all adult patients with ≥3+ mitral regurgitation who underwent mitral valve repair or replacement were identified. Postoperative outcomes and midterm time-to-event rates (survival and reoperation) were compared., Results: Overall, 94 atrial FMR (mean age, 67.6 years) and 84 ventricular FMR (mean age, 64 years) patients met inclusion criteria. Differences in baseline cardiac morphology and function of the atrial FMR and ventricular FMR patients were as follows: concomitant atrial fibrillation (37.2% vs 14.3%), heart failure (42.6% vs 63.1%), LV ejection fraction (60% vs 37%), at least moderate LV dilation (4.8% vs 40.6%), and moderate/severe right heart dysfunction (15.2% vs 5.1%), respectively. Operative mortality was 0% in the atrial FMR versus 1.2% in the ventricular FMR cohort. Actuarial estimates of survival and freedom from reoperation at 5 and 10 years was significantly higher in the atrial FMR cohort versus the ventricular FMR cohort. Ventricular FMR also remained a significant predictor of midterm mortality in our risk-adjusted analysis (adjusted hazard ratio for ventricular FMR, 1.8; 95% confidence interval, 1.001-3.26)., Conclusions: There are important differences in baseline characteristics in terms of cardiac morphology and function among atrial FMR and ventricular FMR patients, which appear to affect in-hospital and midterm outcomes. Because of these discrepancies, early discrimination between these 2 etiologies of FMR might facilitate more tailored approaches to management., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the impact of hospital size on national trend estimates of isolated open proximal aortic surgery for benchmarking hospital performance., Methods: Patients age >18 years who underwent isolated open proximal aortic surgery for aneurysm and dissection from 2002 to 2014 were identified using the National Inpatient Sample. Concomitant valvular, vessel revascularization, re-do procedures, endovascular, and surgery for descending and thoracoabdominal aorta were excluded. Discharges were stratified by hospital size and analyzed using trend, multivariable regression, propensity-score matching analysis., Results: Over a 13-year period, 53,657 isolated open proximal aortic operations were performed nationally. Although the total number of operations/year increased (∼2.9%/year increase) and overall in-hospital mortality decreased (∼4%/year; both P < .001 for trend), these did not differ by hospital size (P > .05). Large hospitals treated more sicker and older patients but had shorter length of stay and lower hospital costs (both P < .001). Even after propensity-score matching, large hospital continued to demonstrate superior in-hospital outcomes, although only statistically for major in-hospital cardiac complications compared with non-large hospitals. In our subgroup analysis of dissection versus non-dissection cohort, in-hospital mortality trends decreased only in the non-dissection cohort (P < .01) versus dissection cohort (P = .39), driven primarily by the impact of large hospitals (P < .01)., Conclusions: This study demonstrates increasing volume and improving outcomes of isolated open proximal aortic surgeries nationally over the last decade regardless of hospital bed size. Moreover, the resource allocation of sicker patients to larger hospital resulted shorter length of stay and hospital costs, while maintaining similar operative mortality to small- and medium-sized hospitals., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the impact of the video-assisted thoracoscopic (VATS) approach on the outcomes of patients who underwent pneumonectomy., Methods: The effect of the surgical approach on perioperative complications and survival in patients who underwent pneumonectomy for nonmetastatic non-small cell lung cancer across 3 institutions (2000-2016) was assessed using multivariable logistic regression, Cox proportional hazards analysis, and propensity-score matching. Completion pneumonectomies were excluded from this study, and an "intent-to-treat" analysis was performed., Results: During the study period, 359 patients met inclusion criteria and underwent pneumonectomy for nonmetastatic non-small cell lung cancer; 124 (35%) underwent pneumonectomy via VATS and 235 (65%) via thoracotomy. Perioperative mortality (VATS, 7% [n = 9] vs open, 8% [n = 19]; P = .75) and morbidity (VATS, 28% [n = 35] vs open, 28% [n = 65]; P = .91) were similar between the groups, even after multivariable adjustment. VATS showed similar 5-year survival when compared with thoracotomy in unadjusted analysis (47% [95% confidence interval (CI), 36-56] vs 33% [95% CI, 27-40]; P = .19), even after multivariable adjustment (hazard ratio, 0.76 [95% CI, 0.50-1.18]; P = .23). In a propensity score-matched analysis that balanced patient characteristics, there were no significant differences found in overall survival between the 2 groups (P = .69)., Conclusions: Although the role of VATS pneumonectomy will likely become clearer as more surgeons report results, this multicenter study suggests that the VATS approach for pneumonectomy can be performed safely, with at least equivalent oncologic outcomes when compared with thoracotomy., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The study objective was to describe the clinical outcomes of elderly patients undergoing ascending aortic surgery., Methods: Patients aged 70 years or older who underwent ascending aortic surgery between January 2002 and December 2013 were examined. Of 415 included patients, 285 were elderly patients (age 70-79 years) and 130 were very elderly (age ≥80 years). Logistic regression and Cox proportional hazards models were used to evaluate operative mortality and long-term survival, respectively., Results: Surgical indications included aortic aneurysm (63.1%), calcified aorta with need for other cardiac procedure (26.4%), and type A dissection (10.5%). Compared with elderly patients, the very elderly patients had a higher burden of comorbidities and operative mortality (13% vs 7%, P < .04). The very elderly patients were also more likely to be discharged to a rehabilitation facility than home (P < .001). However, risk-adjusted operative mortality and 30-day readmissions rates were similar (P > .05). Kaplan-Meier estimates of survival at 1 and 5 years were 85.6% and 72.6% for elderly patients versus 79.2% and 57.1% for the very elderly patients. Age was a strong risk variable for late mortality in the unadjusted and adjusted analyses., Conclusions: After adjusting for these comorbidities, the cause of aortic disease, and the type of procedure, age was not an independent predictor of operative mortality, but was strongly associated with reduced late survival. Thus, advanced age alone should not be an absolute contraindication for ascending aortic surgery., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: With the emergence of transcatheter mitral valve-in-valve/ring replacement for deteriorated bioprostheses or failed repair, comparative clinical benchmarks for surgical repeat mitral valve replacement (re-MVR) are needed. We present in-hospital and survival outcomes of a 24-year experience with re-MVR., Methods: From January 1992 to June 2015, 520 adult patients underwent re-MVR; 273 had undergone prior mitral valve repair (pMVP) and 247 had undergone prior MVR (pMVR). A benchmark cohort of isolated re-MVR was defined based on potential eligibility for transcatheter mitral valve-in-valve/ring replacement, resulting in 73 pMVPs with previous annuloplasty rings and 74 pMVRs with previous bioprosthetic valves for comparison., Results: For the entire cohort, mean age was 64 ± 12 years for pMVP patients and 63 ± 15 years for pMVR patients (P = .281), which was similar for the benchmark cohort. Overall operative mortality was 14 out of 273 (5%) for pMVP versus 23 out of 247 (9%) for pMVR (P = .087). There were 3 operative deaths (4.1%) in both groups of the benchmark cohort (P = 1.0). For the benchmark cohort, median time to reoperation was 9.8 years for pMVP and 9.1 years for pMVR. Cox proportional hazard analysis showed that chronic kidney disease (hazard ratio [HR], 2.47; 95% CI, 1.77-3.44), endocarditis (HR, 1.49; 95% CI, 1.07-2.07), pMVR (HR, 1.45; 95% CI, 1.12-1.89), early reoperation ≤ 1 year (HR, 1.49; 95% CI, 1.02-2.17), and age (HR, 1.04/y; 95% CI, 1.03-1.05) were associated with decreased survival after re-MVR., Conclusions: A re-MVR is a high-risk operation, but in carefully selected patients such as our benchmark population, it can be performed with acceptable results. Patients undergoing pMVP also have better long-term survival compared with patients undergoing pMVR. These results will serve as a benchmark for transcatheter mitral valve-in-valve/ring replacement., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)