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Abstract Background The optimal timing for administering dual antiplatelet therapy (DAPT) post-coronary artery bypass grafting (CABG) remains a subject of debate. This study aimed to evaluate the safety and efficacy of early DAPT administration within 6 h post-CABG, following the implementation of a new standard operating procedure (SOP). This study was conducted in three phases at the National Heart Institute of Malaysia. Phase 1 involved a clinical audit of 80 isolated CABG patients to evaluate current DAPT practices. Phase 2 was a pilot study involving 320 patients to establish criteria for early DAPT initiation. Phase 3 comprised a prospective cohort analysis comparing outcomes between 939 propensity-matched pairs receiving early/new SOP ( 6 h) DAPT. Results The clinical audit revealed a mean DAPT administration time of 18.3 h post-CABG, highlighting variability in practice. The pilot study demonstrated that early DAPT was associated with a significantly lower chest reopening rate (0.8% vs. 21.6%) under stringent selection criteria. In the follow-up study, early DAPT was linked to reduced rates of postoperative stroke (1.0% vs. 2.5%, p = 0.013), dialysis (5.5% vs. 7.0%, p

Abstract Background This study investigated the impact of preoperative right ventricular (RV) dysfunction and dilatation on survival outcomes following left ventricular surgical restoration (LVSR) in patients with ischemic cardiomyopathy. A retrospective analysis was conducted on 137 patients who underwent LVSR between 2009 and 2021. Results The results indicated that hospital mortality was significantly associated with older age [OR, 1.10; P = 0.01], higher EuroSCORE II [OR, 1.08, P = 0.03], recent myocardial infarction [OR, 4.24, P = 0.02], lower creatinine clearance [OR, 0.97, P = 0.02], and left ventricle longitudinal [OR, 0.95, P

Abstract Background The practice of routine preoperative head ultrasound (HUS) screening for infants and neonates undergoing surgery for congenital heart disease has been widely adopted; however, its usefulness is still unclear. Therefore, this study aimed to determine the prevalence of preoperative HUS abnormalities in neonates and infants with congenital heart disease, its association with postoperative neurological outcomes, and its sensitivity and specificity in detecting preoperative abnormalities. This retrospective cohort study was conducted between 2015 and 2022 at a tertiary referral center. The study included 596 children who were scheduled for cardiac surgery for congenital heart disease and who had preoperative HUS. Results The prevalence of preoperative HUS abnormalities was 23% (n = 137). There were no differences in the baseline characteristics between patients with normal and abnormal HUS. The most common abnormality reported by HUS was intraventricular hemorrhage (IVH) (n = 65, 47.45%). Surgery was done in 417 (78.53%) with no IVH vs. 50 (76.92%) with IVH (P = 0.766). Mortality was statistically not significantly higher in patients with abnormal HUS (14% vs. 8%; P = 0.092). Twenty-seven patients developed new postoperative neurological complications (5.78%), with no difference between the groups (5.7% vs. 6.1%, P = 0.893). Preoperative neurological abnormalities (OR: 1.24 (95% CI: 1.08–1.41); P = 0.002) and intrauterine growth retardation (OR: 5.37 (95% CI: 1.61–17.88), P = 0.006) were significantly associated with new postoperative neurological events. The sensitivity of HUS compared with that of MRI was 51%, and the specificity was 83%. Conclusions The HUS showed a high percentage of abnormal findings in children with congenital heart disease; however, these findings were not necessarily correlated with the outcome. The study findings do not support the routine use of HUS for neonates and infants undergoing surgery for congenital heart disease. Abnormal HUS findings did not significantly impact surgical rates or postoperative outcomes.

Abstract Background Factors affecting the outcomes after Fontan palliation are still controversial. Thus, this study aimed to compare hospital and long-term outcomes after Fontan palliation in patients with left-dominant, right-dominant, and co-dominant ventricles. Moreover, the study sought to identify factors associated with long-term surgical reintervention, catheter-based interventions, and morality. This retrospective cohort study was conducted in a single tertiary referral center between 2010 and 2024 and included all patients who had Fontan palliation (n = 247). The patients were grouped according to the dominant ventricle into three groups: left-dominant (n = 105), right-dominant (n = 108), and codominant (n = 36). Results No significant differences were found in demographic variables among groups. Heterotaxy was more common in codominant patients who exhibited higher preoperative saturation levels. Early postoperative complications were more frequent in right-dominant patients, with low cardiac output significantly lower in left-dominant patients. Codominant patients experienced more arrhythmias and complete heart block, while operative mortality rates were similar across groups. During a median follow-up of 80 months, the freedom from surgical reintervention at 5, 10, and 15 years was highest in the left-dominant group (97%) compared to right dominance (93%, 78%) and codominance (97%, 87%). Mortality was significantly higher in the right-dominant and codominant groups, with survival rates at 5, 10, and 15 years being 97% for left dominance, 92% for right dominance, and 91% for codominance. Factors influencing long-term mortality were older age, right dominance, and elevated pulmonary artery pressure. Conclusions Patients with left dominance exhibited superior survival rates and fewer complications compared to those with right dominance and codominance. The findings emphasize the importance of anatomical considerations in risk stratification and clinical decision-making. Young age at the time of palliation could improve the outcomes of the Fontan procedure.

Abstract Background Accurate reflections of long-term outcomes of isolated tricuspid valve surgery are underreported in the literature. Most published cohort studies consisted of patients receiving tricuspid valve surgery concomitant with left-sided procedures. Patients who undergo isolated tricuspid valve surgery usually present late for surgery, with deteriorating risk factors leading to increased surgical risk. Thus, this study aimed to compare the short- and long-term outcomes of isolated tricuspid valve surgery with those of tricuspid surgery concomitant with left-sided valve procedures. This retrospective cohort study included 617 patients who underwent isolated and left-sided concomitant tricuspid valve surgery from 2009 to 2020. We grouped the patients into isolated (n = 63) vs. concomitant tricuspid surgery (n = 554). Results Isolated tricuspid surgery was associated with significantly greater rates of operative mortality (19% vs. 5.2%, P 24 h (22.22% vs. 12.27%, P = 0.028). ICU (3 days vs. 2 days, P = 0.005) and hospital stays (13 days vs. 11 days, P = 0.042) were significantly longer in isolated tricuspid surgery patients. Isolated tricuspid surgery independently predicted hospital mortality (OR: 4.00 (95% CI: 1.59–10.05), P = 0.003). The risk of follow-up mortality was higher in patients with isolated surgery (HR: 1.95 (95% CI: 0.98–3.86); P = 0.055). However, isolated tricuspid surgery was not associated with heart failure rehospitalization (HR: 1.11 (95% CI: 0.51–2.41); P = 0.798) or increased tricuspid valve reinterventions (HR: 1.42 (95% CI: 0.51– 3.92); P = 0.499). Conclusions Isolated tricuspid surgery independently predicted hospital mortality and was associated with nonsignificantly higher long-term mortality. This finding highlights the importance of timely referral and intervention for patients with isolated tricuspid valve disease to optimize short- and long-term outcomes.

Abstract Background Surgery for malignant pleural mesothelioma (MPM) has always been a source of debate since no strong evidence exists for performing a radical surgical intervention. We aim to systematically review and compare different macroscopic resection procedures. A systematic Review on PUBMED/MEDLINE, EMBASE, and COCHRANE LIBRARY from Inception until March 2024 was performed to search for all studies comparing the 30-day mortality and overall survival after extrapleural pneumonectomy (EPP) and Pleurectomy decortication or extended Pleurectomy decortication (PD/EPD). We excluded studies with less than 10 patients, case reports, and articles with no endpoints. Main body Our electronic search retrieved 18,124 citations of which 22 studies fulfilled our criteria. The median 30-day mortality for PD/EPD was 2.2% (range 0–4%) while the median overall survival was 21 months (range 10.4–36 months) while EPP has a median 30-day mortality of 6% (range 0–11.8%) with a median overall survival of 18.1 months (range 9.3–35 months). Conclusion Surgery for MPM should be for selected patients and performed in specialized centers after discussions in multidisciplinary team meetings. PD/EPD seems to be associated with a lower 30-day mortality rate and a superior overall survival and should be considered the first radical option if surgery is deemed appropriate for patients.

Advanced heart failure (AHF) is a major problem with an aging population and profound unmet needs. While heart transplant offers the most definitive solution, it is largely unavailable for most and mandates a long waiting period. Left ventricular assist devices (LVADs) help in expanding the treatment armamentarium to those for whom transplant is either a contraindication or unavailable (destination therapy) and those who need stabilization before transplant (bridge to transplant). LVADs are truly a renaissance in the management of AHF as they make treatment available to a much larger population and improve not only symptoms and quality of life but also survival as compared to patients on medical therapy only. Consequently, they have now been adopted in many European centres as destination therapy with a median survival of 7 years in patients with a LVAD implantation. LVADS are plagued with multiple complications, and while they do offer an opportunity of improved survival, the patients often are plagued with morbid complications. Newer advances in technology have paved the way for smaller and better engineered devices with lesser complications like bleeding and pump thrombosis. We review briefly the burden of advanced Heart Failure, evolution of LVADs, current status and the future of these devices.

Introduction: Numerous nonpharmacological interventions are being investigated for cardioprotective effects among individuals with acute myocardial infarction (MI) who underwent revascularization. However, results of these trials are contradictory. This review aimed to explore the emerging nonpharmacological interventions to prevent myocardial reperfusion injury (RI). Materials and Methods: This review followed Introduction, Methods, Results, Discussion pattern for nonsystematic reviews. Article published form 2015 to November 2023 were retrieved from PubMed, Science direct, and Scopus. Population, Intervention, Comparator, Outcomes, Study design format was used to assess the eligibility of articles where population was ST elevated MI; Intervention was any nonpharmacological interventions such as ischemic postconditioning, therapeutic hypothermia, low level laser therapy (LLLT), remote ischemic conditioning (RIC), and therapeutic hyperoxemia; Comparator can be placebo/sham or control groups, Outcomes were infarct size and cardiac biomarkers and study design can be randomized clinical trials, pre–post experimental studies, etc. Results: 15,889 articles were identified and after duplicate removal and assessing eligibility criteria, 27 articles were included in this review. Out of 27, 7 studies used ischemic post conditioning where only 3 studies revealed improvements in ejection fraction and reduction in cardiac biomarkers; 12 studies employed RIC in which only 2 studies showed improvements in ejection fraction whereas 5 showed reduction in peak cardiac biomarkers, 7 experimental studies used therapeutic hypothermia in which only 1 study showed reduction in infract size postintervention, and one study used LLLT where reduction in cardiac biomarkers was seen postintervention. Conclusion: Ischemic postconditioning and RIC showed significant results on myocardial RI whereas therapeutic hypothermia revealed nonsignificant results in most of the trials and failed to prove its efficacy in preventing Myocardial RI. However, a new intervention LLLT proved to be significantly effective in preventing myocardial RI in one human clinical trial.

Background: Atypical presentations of acute coronary syndrome (ACS) delay its recognition and treatment in older adults. During hospitalization, functional decline and delirium which are common to elder patients, lead to prolonged hospitalization, frailty, and poor clinical outcome. Steps taken for its prevention are usually not considered the top priority by the cardiologist. The present study was conducted to identify frailty among older adults who developed ACS during hospitalization for noncardiac illness and their outcome. Materials and Methods: Three hundred and ten older adults with ACS were included from June 26, 2020, to October 13, 2020. Subjects were divided into those admitted primarily due to an ACS (Group I, n = 94) and those developing ACS following admission for noncardiac illness (Group II, n = 216). Comorbidities, medications, investigations, management, outcome, and clinical frailty scale were compared between the two groups at the time of admission, after 30 days, and after 6 months. Results: Majority of them had non-ST elevation ACS (90.2%) in Group II, and acute kidney injury (27.1%) was the most common reason for admission. Optimum management was given to a lesser extent due to the current clinical condition of these patients. Frailty and physical disability during hospitalization and follow-up were more in Group II. Conclusion: Clinicians must be vigilant for the development of frailty when an older adult is admitted to the hospital, as early detection and optimum management provide better clinical and functional outcomes.

Introduction: Hypertension (HTN), the third risk factor driving death and disability as per Global Burden of Disease 2019, is a major public health concern. Prehypertension, the intermediate stage between HTN and normal blood pressure (BP), is associated with subclinical atherosclerosis and target-organ damage. Evaluating the prevalence of prehypertension is imperative to prevent disease progression. Prehypertension, alike HTN, is a complex disorder that manifests when genes are triggered by the environment. The current study attempts to evaluate the prevalence of prehypertension in a tribal population of Northern India. Further, the association with extensively studied renin–angiotensin system (RAS) pathway genes with prehypertension has been explored. Methods: A cross-sectional study was conducted on adults of 20–60 years old belonging to a tribal community, Rang Bhotia of Northern India. Information on demographic, lifestyle, and anthropometric risk factors was collected. The blood sample was collected for lipid and genetic analysis. DNA extraction and genotyping of five genetic markers of RAS-related pathway were performed. Chi-square and t-tests were used for assessing significant differences between the groups. Logistic regression was used to examine the association of genes with prehypertension and HTN. Results: Among 254 adults participating in the study, 39% and 42% had prehypertension and HTN, respectively. T allele of M235T genetic marker was found to be posing two-fold risk for prehypertension (odds ratio [OR] = 2.9; 95% confidence interval [CI] =1.10–7.72; P = 0.03 in dominant model and OR = 1.83; 95% CI = 1.09-3.09; P = 0.02 in additive model) after adjusting for age and sex. On the other hand, G allele of A6G polymorphism was found to be providing protection toward prehypertension (OR = 0.32; 95% CI = 0.11–0.92; P = 0.03 in recessive model and OR = 0.55; 95% CI = 0.32–0.94; P = 0.03 in additive model). Conclusion: More than one-third of individuals exhibited prehypertension, suggesting an impending burden of HTN and comorbidities among the tribal population in the near future. Moreover, increased genetic susceptibility toward elevated BP commands immediate attention. Effective management strategies including interventions on lifestyle, diet modification, and weight management need to be introduced to combat increasing HTN among the tribal population.

Introduction: Cardioplegia is crucial for myocardial protection during cardiac surgery. However, the impact of different cardioplegia formulations on patients’ metabolomic responses has not been explored. The objective is to identify unique metabolomic signatures associated with each cardioplegia type and evaluate their potential correlations with clinical outcomes. Methods: A prospective cohort study was conducted from January 2023 to June 2024, involving 105 samples from 21 patients undergoing isolated coronary artery bypass graft with modified del Nido, Custodiol®, or St. Thomas cardioplegia. Pre- and postoperative plasma samples were collected for analysis of cardiac enzyme levels and proton nuclear magnetic resonance metabolomic profiling. Results: No significant differences in clinical outcomes or cardiac enzyme levels were observed between the groups. However, distinct pre-and postoperative metabolomic profiles were identified. The Custodiol group exhibited significant postoperative metabolomic changes within the first 2 days, with nine differentially expressed metabolites (DEMs). In contrast, modified del Nido cardioplegia affected three DEMs on postoperative day 0, whereas St. Thomas showed no alteration in the postoperative metabolomic profile. These DEMs were associated with protein and energy production, oxidative stress, and inflammatory responses. Key differential metabolites between the groups included histidine and alanine, which notably impacted the histidine metabolism pathway. Conclusion: The findings demonstrate that distinct cardioplegia solutions result in differential postoperative metabolomic alterations, with Custodiol exhibiting the most pronounced shifts, whereas St. Thomas cardioplegia showed no significant postoperative metabolic changes.

A middle-aged patient presented with symptoms of shortness of breath. He had been operated for a heart disease many years ago. He had a history of cough, hemoptysis, and a recent febrile episode. Clinical examination revealed a slow rising pulse and both systolic and diastolic murmurs. The electrocardiogram and echocardiogram were reviewed. The stepwise diagnostic approach to a patient with valvular heart disease starting from history to examination and then evaluation of the investigations and planning the treatment is discussed for the training of cardiology fellows.

A young boy presented with palpitations and shortness of breath. He had a history of recurrent chest infections as a child. The clinical approach to such a patient along with correlation from investigations is discussed as a teaching exercise for cardiology fellows in training.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly, which usually presents in infancy, and survival to adulthood is very rare, around 10–15%. We report a 46-year-old female with no risk factors, who presented with a history suggestive of acute left heart failure of two weeks duration. Echocardiography revealed acute severe mitral regurgitation (MR) with flail posterior mitral leaflet (PML) due to chordae tendinae rupture (CTR) with normal left ventricular function and dimensions. There were no features suggestive of infective endocarditis, rheumatic or myxomatous affection of mitral valve. During preoperative workup, coronary angiography revealed the presence of ALCAPA which was confirmed by computed tomography. The patient underwent successful surgical repair of ALCAPA along with mitral valve replacement. The case underscores unusual association of ALCAPA in an adult age with acute severe MR secondary to flail PML due to CTR with a possible ischemic causal relationship.

The illness known as nonbacterial thrombotic endocarditis (NBTE) is characterized by the deposition of fibrin and thrombi on deteriorated or normal heart valves without microbes. Compared to infective endocarditis, this disease is more frequently observed in chronic inflammatory conditions and is linked to a higher incidence of thromboembolic events. Vegetations on two-dimensional echocardiography and negative blood cultures suggest the disease. It is generally associated with advanced malignancies and very rarely with squamous cell carcinoma (SCC) of the esophagus. Here, we describe the case of a 68-year-old female with SCC of the esophagus who developed NBTE.

Congenital corrected transportation of great arteries (ccTGA) is a rare congenital heart disease, accounting for < 1% of congenital heart diseases. It remains undiagnosed until adulthood, in the absence of associated congenital anomalies. Adults with ccTGA are usually asymptomatic or their diagnosis may be missed during initial evaluation. It is sometimes diagnosed inadvertently while evaluating a murmur or a low heart rate. We aim to report three cases of ccTGA with varied presentations. We presented three cases of ccTGA with varied presentation, two cases of complete heart block requiring permanent pacemaker, out of which one had situs inversus totalis with levocardia, the other had situs solitus. The 3rd case was presented as case of ccTGA with heart failure with viseroarterial situs solitus, large atrial septal defect, large inlet ventricular septal defect, and severe pulmonary stenosis and had undergone bidirectional Glenn shunt. These cases illustrate the challenges confronted in adult practices when patient with unrecognized ccTGA presents during initial visits. Congenital corrected transposition of great arteries is rare congenital anomaly that poses a challenge in adulthood due to its varied presentation. Thus, an increased awareness about key diagnostic features is crucial for early recognition of ccTGA and its effective management.

Graves’ disease commonly presents with thyroid and extrathyroid manifestations. Cardiovascular manifestations are present in 6% of patients. Only 1% of patients has dilated cardiomyopathy and acute heart failure, which is an unusual presentation of Graves’ disease. An elderly male patient presented with acute heart failure, atrial fibrillation, renal impairment, and secondary to hypotension, diagnosed with dilated cardiomyopathy and significant left ventricular (LV) dysfunction. His test results revealed an increase in T3 and T4 levels with a low thyroid-stimulating hormone (TSH), as well as positive antithyroid antibodies and TSH receptor antibodies, confirming Graves’ disease. The patient improved symptomatically with antiheart failure treatment and antithyroid drugs. On follow-up, his LV dysfunction completely recovered. This instance emphasizes the need of screening heart failure patients to identify reversible causes of heart failure and provide suitable treatment.

Objective: Previous retrospective studies have established a relationship between postoperative hypoglycemia and adverse outcomes after cardiac surgery, but none have accounted for the cause of hypoglycemia. Methods: A retrospective review was performed of patients who underwent cardiac surgery at a single institution between 2016 and 2021. Patients were categorized as hypoglycemic if they had 1 or more postoperative blood glucose measurement less than 70 mg/dL and normoglycemic otherwise. Hypoglycemia was subcategorized as noniatrogenic (underlying liver failure, adrenal insufficiency, sepsis, or shock) or iatrogenic (insulin infusion continued while nil per os or infusion protocol violated) via manual chart review. Baseline characteristics were compared between groups using Pearson χ2, analysis of variance, and Kruskal-Wallis testing, and outcomes were compared using multivariable logistic regression. Results: In total, 5373 patients and 183,346 glucose measurements were included. Hypoglycemia occurred in 5% (267) of patients, of whom 63% (169) were iatrogenic and 37% (98) were noniatrogenic. In a multivariate analysis adjusting for age, sex, case urgency, pre-existing diabetes, and bypass time, both iatrogenic and noniatrogenic hypoglycemia were associated with greater odds of renal failure, prolonged ventilation, and prolonged intensive care unit length of stay relative to normoglycemia, but the magnitude was substantially lower in iatrogenic hypoglycemia. Patients with noniatrogenic hypoglycemia had 68.6 times greater odds of mortality relative to patients who were normoglycemic (odds ratio, 68.6; confidence interval, 39.5-119), but patients with iatrogenic hypoglycemia had no increased odds of mortality (odds ratio, 1.45; confidence interval, 0.77-2.73). Conclusions: When excluding patients with conditions known to cause hypoglycemia from the analysis, the morbidity and mortality of iatrogenic hypoglycemia from tight postoperative glycemic control is dramatically attenuated.

Objective: The management of preoperative medications is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Numerous guidelines and expert consensus documents have been published to provide guidance in preoperative medication management. Our objective is to integrate these documents into an evidence-based order set that will facilitate standardized implementation of best practices for preoperative medication management for nonemergent adult cardiac surgery. Methods: Subject matter experts were consulted to translate existing guidelines and peer reviewed literature into a sample turnkey order set for the preoperative management of patients’ medications. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. Results: Holding antiplatelet and anticoagulant medications before nonemergent cardiac surgical procedures may reduce the risk of bleeding. Sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 agonists should also be discontinued to prevent acidosis and aspiration, respectively. Specific guidance for frequently used medications are complied within the manuscript, less frequently used medications are listed seperately. Conclusions: Despite strong recommendations from major guidelines and consensus manuscripts, variation exists in preoperative medication orders, with limited availability of succinct implementation tools. This turnkey order set may facilitate standardized comprehensive preoperative medication management before nonemergent cardiac surgery.

Objective: The concept of proportionate and disproportionate functional mitral regurgitation suggests that transcatheter edge-to-edge mitral repair may benefit patients with a smaller left ventricle relative to a higher regurgitant burden. The clinical relevance of proportionality remains unknown in mitral operations for ischemic mitral regurgitation. We aimed to characterize the association between mitral regurgitation proportionality and outcomes after mitral valve operations. Methods: By using the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial, we first identified the inflection point at which the risk of 2-year mortality changed along the spectrum of the mitral regurgitation proportionality (defined as effective regurgitant orifice area/left ventricular end-diastolic volume index) using a splined multivariable Cox proportional hazards model. Patients were dichotomized by the mitral regurgitation proportionality value. The Cox model evaluated the hazard of 2-year all-cause mortality between proportionate and disproportionate mitral regurgitation. Results: Among the 240 patients, the median age was 69 years (interquartile range, 62-75), and 38% (n = 90) were women. Patients with effective regurgitant orifice/left ventricular end-diastolic volume index proportion greater than 0.40 (more disproportionate mitral regurgitation) had a higher hazard of death compared with those with more proportionate mitral regurgitation. The 90-day and 1-year mortality were higher in patients with disproportionate mitral regurgitation (13% vs 6.2% for 90 days and 19% vs 12% for 1 year). In a multivariable Cox model, the disproportionate mitral regurgitation group had a statistically significantly higher hazard of death compared with the proportionate mitral regurgitation group (hazard ratio, 2.15, 95% CI, 1.16-3.98, P = .015). Conclusions: The clinical relevance of the proportionality of functional mitral regurgitation proposed in the transcatheter edge-to-edge mitral repair population may not generalize to surgical patient populations.

Background: Minimally invasive mitral valve repair (MIMVR), often performed within specialized care pathways, has been shown to reduce hospital length of stay and improve patient recovery. The relative value of rapid-recovery protocols as a component of care pathways, including enhanced recovery programs (ERPs), has not been well described. This study compared clinical outcomes following implementation of a new, comprehensive rapid-recovery protocol within a previously established, mature ERP for patients undergoing MIMVR. Methods: The rapid-recovery protocol was developed and implemented by a multidisciplinary team to further optimize patient recovery within an existing ERP. The protocol was applied to 75 consecutive patients undergoing MIMVR between September 2022 and December 2023. Outcomes were compared retrospectively to 75 ERP control patients who did not receive the rapid-recovery protocol but experienced the ERP. The primary outcome was a composite of discharge from the intensive care unit (ICU) by postoperative day (POD) 1, discharge to home by POD 4, and no all-cause hospital readmission by 30 days. Results: Baseline characteristics were similar in the 2 groups. Patients in the rapid-recovery group achieved the primary composite outcome significantly more often compared to the control group (60% vs 40%, respectively). There was no between-group difference in postoperative complications. Multivariable logistic regression showed that age ≤60 years was significantly associated with rapid-recovery protocol success. Clinical barriers to achieving individual components of the primary outcome were described. Conclusions: A rapid-recovery protocol for MIMVR was associated with early ICU and hospital discharge. These benefits were safely achieved without any increase in hospital readmission, morbidity, or mortality up to 30 days postoperatively.

Objective: There are limited data on the outcome of routine cardiac operations in patients with cardiac amyloidosis. This study studied the impact of amyloidosis on early and late results of cardiac operations. Methods: This was a retrospective, propensity-matched, case-control study of patients with cardiac amyloidosis undergoing cardiac surgery. Heart transplantation and ventricular assist implantation were excluded. Controls were patients without known cardiac amyloidosis matched on baseline patient characteristics, echocardiographic findings, and type of operation. Outcomes included operative complications and survival. Results: In total, 42 patients with cardiac amyloidosis (amyloid group [AG]) were matched with 168 controls (CON group). The median left ventricular ejection fraction was 63% in the AG group (vs 64% CON). Aortic valve replacement and septal myectomy were the most common operations. Cardiopulmonary bypass (P = .374) and crossclamp (P = .185) times were similar in the 2 groups. Complication rates were similar in the 2 groups, including the need for mechanical circulatory support (n = 1 AG group vs n = 1 CON; P = .361) and intra-aortic balloon pump use (n = 3 AG group vs n = 13 CON; P = 1.000). There were no operative deaths. Survival was similar in the 2 groups at 1 year (AG 93% vs 89% CON; P = .1) but was worse in the AG at 5 years (59% vs 68% CON; P = .1). Conclusions: Early procedural outcomes and 1-year survival are similar in patients with and without cardiac amyloidosis with preserved cardiac function. Diagnosis of amyloidosis should not be a contraindication to cardiac surgery.

Objective: To investigate the influence of cannabis consumption on the mid- and long-term surgical outcomes of patients with aortic aneurysms or dissections. Methods: All individuals aged 18 years and older with more than 6 months of cannabis use at the time of surgical repair for cardiovascular disease (aortic aneurysms or aortic dissection) between 2007 and 2023 were eligible. Patients were stratified into 2 groups based on their preoperative history of cannabis use: cannabis users and noncannabis users. The primary end point was complications or death within 30 days of intervention. Secondary outcomes included late complications and reinterventions. Data were combined from our institution and inpatient hospital records. Results: We identified 134 patients who met the inclusion criteria out of 1543 treated patients (9%). Compared with the nonusing cannabis group, individuals in the cannabis group were significantly younger (cannabis: 48.3 ± 11.8 years vs noncannabis: 58.5 ± 14.9 years; P

Objective: To evaluate the effectiveness of the five-minute drainage assessment (FMDA) in preventing reexploration for bleeding following cardiovascular surgery. Methods: This retrospective review included 1280 patients who underwent cardiovascular surgery between January 2017 and August 2021. Patients were divided into control (n = 695) and FMDA (n = 585) groups. The FMDA involved estimating the bleeding volume from 1 drainage tube every 5 minutes during sternal closure. Reexploration rates, postoperative bleeding volumes, and clinical outcomes were compared between the 2 groups. Results: The FMDA group had a significantly lower rate of reexploration for bleeding than the control group (2.2% vs 4.3%; P = .038). The median postoperative bleeding volume within 24 hours was significantly lower in the FMDA group compared to controls (630 mL vs 695 mL; P = .009). Multivariable logistic regression analysis demonstrated that the FMDA was independently associated with a reduced risk of reexploration for bleeding (odds ratio, 0.49; 95% confidence interval, 0.25-0.96; P = .037). The FMDA demonstrated good discriminatory ability for identifying patients at risk of reexploration (area under the receiver operating characteristic curve = 0.782), with an optimal cutoff of 21.0 mL. Conclusions: Implementation of the FMDA was associated with a significantly lower rate of reexploration for bleeding compared to the control group. The FMDA provides a simple and reproducible approach that can be readily adopted in surgical practice.

Objective: Pediatric cardiac surgery site infections (SSI) represent significant morbidity. Our institution reported elevated SSI rates of 3.48 per 100 cases over a 5-year period above target rates of 2.5 per 100 cases. Therefore, as a quality improvement initiative, we implemented interventions with the goal of decreasing SSI rates by 30%. Methods: Pediatric cardiovascular surgery patients (January 2021 to August 2023) who had SSI within 30 days of index operation were included (n = 1514) based on the National Healthcare Safety Network definition. Descriptive statistics were used to compare our preintervention cohort (pre-IV) (January 2021 to April 2022; n = 753) and postintervention cohort (post-IV) (May 2022 to August 2023; n = 761). Results: In the post-IV cohort, we found a significant decrease in total SSI (1.97 SSIs per 100 cases [15 out of 761]) versus pre-IV (3.85 SSIs per 100 cases [29 out of 753]), demonstrating a 48% reduction (P = .029). In our post-IV cohort, there was a significant reduction in superficial SSIs (pre-IV, 3.19 SSIs per 100 cases [24 out of 753] vs post-IV, 1.58 SSIs out of 100 cases [12 out of 761]; P = .04). Wounds presenting at 1 to 3 weeks were also reduced in our post-IV cohort (pre-IV, 2.66 SSIs per100 cases [20 out of 753] vs post-IV, 0.66 SSIs per 100 cases [5 out of 761]; P = .002). A significant reduction in SSIs in nonneonates was also noted (pre-IV, 2.79 SSIs per 100 cases [21 out of 753] vs post-IV, 0.92 SSIs per 100 cases [7 out of 761]; P = .007). Additionally, there was a significant reduction in SSIs associated with the Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery 1 mortality category (P = .033) and the number of readmissions in the post-IV cohort (P = .042). Conclusions: A new surgical site dressing and multidisciplinary surveillance plan effectively reduced the overall burden of SSI rates at our institution. Future studies will address risk factors in specific subpopulations to further reduce SSIs at our institution.

Objective: Optimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management. Methods: Subject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. Results: Opioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery. Conclusions: There has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.

Objective: The optimal method for cerebral protection during aortic arch reconstruction in neonates and infants is unknown. We compare the outcomes of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion strategies in neonatal and infant cardiac surgery. Methods: We retrospectively identified all patients aged less than 1 year who underwent aortic arch reconstruction from 2012 to 2023. Patients were categorized on the cerebral perfusion strategy used during their procedure. Comparative analyses of perioperative and outcome variables were conducted to assess differences between cerebral protection strategies. A secondary analysis further stratifying by complexity of repair was performed. Examples of “complex” repair included the Norwood procedure, and “simple” repairs included isolated arch reconstructions. Adjusted regression models were used to identify specific outcomes associated with cerebral perfusion strategy used. Results: There were 165 cases included in our cohort (114 [69%] selective antegrade cerebral perfusions and 51 [31%] deep hypothermic circulatory arrests). Overall, hospital mortality was 7% (selective antegrade cerebral perfusion 9% vs deep hypothermic circulatory arrest 2%, P = .17). There were 6 total neurologic events in 4 patients after surgery in the selective antegrade cerebral perfusion group and none in the deep hypothermic circulatory arrest group. Irrespective of the cerebral perfusion strategy, there were no differences in mortality, stroke, seizures, renal failure, and catheterization reinterventions observed after surgery. This finding held true even when stratifying cerebral perfusion methods by complexity of repair. Regression analysis showed no associations for cerebral perfusion strategy with any outcome even after adjusting for age and complexity of repair. Conclusions: There were no significant short-term differences and a low rate of neurologic events in both groups during aortic arch reconstruction among neonates and infants. Longer follow-up is necessary to evaluate the impact of cerebral perfusion strategy on neurocognitive development later in life.

Objective: This study compares early and long-term outcomes following mitral valve (MV) repair and replacement in patients with mitral regurgitation (MR) and reduced left ventricular ejection fraction (LVEF). Methods: Patients with primary or secondary MR and LVEF

Objective: The study objective was to evaluate outcomes of patients directly bridged with venoarterial extracorporeal membrane oxygenation to heart transplantation. Methods: A single-center retrospective study was performed on 1152 adult patients undergoing isolated cardiac transplantation between January 2007 and December 2021. Among these, patients bridged with an extracorporeal membrane oxygenation to transplantation (extracorporeal membrane oxygenation group, n = 317) were compared with standard cohorts of patients (no extracorporeal membrane oxygenation group, n = 835). A period analysis (Era 1, 2007-2013, vs Era 2, 2014-2021) was performed. Results: Median duration of extracorporeal membrane oxygenation support before transplantation in the extracorporeal membrane oxygenation group was 8 days. Recipients of extracorporeal membrane oxygenation group were younger, with a better renal function and a shorter time on the waiting list. They were allocated to younger donors, with a longer ischemic time. The extracorporeal membrane oxygenation group and no extracorporeal membrane oxygenation group showed similar 1-year and 9-year survivals: 79.2% versus 79.4%, P = .98, and 56.2% versus 53.9%, P = .59, respectively. Period analysis in the extracorporeal membrane oxygenation group showed improved 1- and 9-year survivals in Era 2 compared with Era 1: 82.7% versus 71.1%, P = .021 and 60.4% versus 50.5%, P = .031, respectively. Era 2 was characterized by a higher rate of patients maintained on extracorporeal membrane oxygenation support after transplantation (92% vs 48%, P

Objective: Evaluate sex differences in patients undergoing repair of acute type A aortic dissection (ATAAD). Methods: Sex-stratified, single-center cohort study of patients undergoing ATAAD repair from 1997 to 2022. The primary outcome was aortic diameter at time of presentation with ATAAD. Secondary outcomes were mortality, myocardial infraction, stroke, hemodialysis, tracheostomy, re-exploration for bleeding, a composite of major adverse events, and long-term survival. Results: In 390 consecutive patients (150 women), men were younger than women (61.0 years; interquartile range [IQR], 50-70 years vs 70.5 years; IQR, 59-78 years; P

Objective: To test the safety and efficacy of combination treatment for pleural mesothelioma (PM) with intracavitary cisplatin-fibrin (cis-fib) plus hemithoracic irradiation (IR) applied after lung-sparing surgery in an orthotopic immunocompetent rat model. Methods: We randomized male F344 rats into 5 groups: cis-fib (n = 9), 10 Gy IR (n = 6), 20 Gy IR (n = 9), cis-fib+10 Gy IR (n = 6), and cis-fib+20 Gy IR (n = 9). Subpleural tumor implantation was performed on day 0 with 1 million syngeneic rat mesothelioma cells (IL45-luciferase). Tumors were resected on day 9, followed by treatment with intracavitary cis-fib or vehicle control (NaCl-fib). On day 12, computed tomography–guided local irradiation in a single high dose of the former tumor region was applied. Results: We observed only short-term side effects related to 20 Gy radiotherapy. Compared to 20 Gy, 10 Gy IR did not show an impact on tumor growth. At 3 days after treatment with 20 Gy IR (day 15 of the experiment), we detected significantly smaller tumors in the cis-fib+IR group compared to IR alone (mean tumor growth, 252% vs 539%; P = .04). On day 21, there was a significant difference in tumor growth between cis-fib–treated and cis-fib+IR– treated tumors (mean tumor growth, 2295% vs 660%; P = .01). Conclusions: Localized treatment after tumor resection in PM aims to improve local tumor control. Irradiation applied in combination with intracavitary cis-fib in rats is safe up to a dosage of 20 Gy and shows an additive effect on tumor growth delay compared to the single treatments.

Objective: This study investigated the efficacy of a multimodal analgesia (MMA) with an opioid-sparing strategy, incorporating a parasternal plane block (PPB) within a systematic standardized Enhanced Recovery After Surgery (ERAS) program for patients undergoing elective cardiac surgery. Methods: From 2015 to 2021, 3153 patients underwent elective coronary artery bypass grafting and/or valve procedures. Patients were dichotomized by the presence or absence of an ERAS program including a perioperative MMA with an opioid-sparing approach and PPB protocols. Propensity score matching yielded 1026 well-matched pairs. The primary outcomes were the opioid-free rate and the opioid consumption in morphine milligram equivalents (MME) in the intensive care unit (ICU). The secondary outcomes were postoperative visual analog scale (VAS) scores, mechanical ventilation duration, ileus, delirium, bronchopneumonia, and length of ICU stay. Results: The ICU opioid-free rate was significantly increased in the ERAS group (94.0%) compared with the control group (19.9%; P

Objective: The superior transseptal approach to mitral valve surgery offers improved exposure compared with left atriotomy; however, concerns remain regarding postoperative arrhythmias and pacemaker placement. This study investigates intraoperative parameters and postoperative outcomes in these approaches. Methods: Retrospective review of 259 adults undergoing isolated mitral valve repair or replacement over a 10-year period was performed. Exclusion criteria included previous history of permanent pacemaker placement and concomitant cardiac procedures. The primary outcome evaluated was postoperative permanent pacemaker placement. Secondary outcomes included postoperative new-onset atrial fibrillation, new-onset arrhythmias, major adverse cardiovascular events, length of stay, and mortality. Results: Of 259 surgeries, 116 were performed via left atriotomy and 143 via superior transseptal approach. The overall incidence of postoperative permanent pacemaker placement was 3.0%, with similar rates (left atriotomy 1.7% vs superior transseptal 4.2%, P = .30). The incidence of new-onset atrial fibrillation (31.0% vs 42.7%, P = .055) and arrhythmias in general (37.1% vs 49.0%, P = .06) was similar. Rates of other secondary outcomes, such as major adverse cardiovascular events and mortality, were similar between cohorts. In addition, cardiopulmonary bypass and aortic crossclamp times did not differ. Interestingly, intensive care unit (55 vs 73 hours, P = .04) and postoperative length of stay (6.8 vs 9.0 days, P = .002) were shorter after left atriotomy. Conclusions: The superior transseptal approach provides optimal exposure while preserving similarly low rates of postoperative morbidity and mortality to left atriotomy. There is no difference in the incidence of postoperative permanent pacemaker placement and new-onset arrhythmias.

Objective: To compare outcomes of aortic valve replacement (AVR) in patients with pure aortic stenosis (Pure AS) and those with pure aortic regurgitation (Pure AR) or mixed AS and AR (MAVD) in the COMMENCE trial. Methods: Of 689 patients who underwent AVR in the COMMENCE trial, patients with moderate or severe AR with or without AS (Pure AR + MAVD; n = 135) or Pure AS (n = 323) were included. Inverse probability of treatment weighting Kaplan-Meier survival curves were used for time-to-event endpoints, and longitudinal changes in hemodynamics were evaluated using mixed-effects models. Echocardiographic outcomes were assessed by an echo core laboratory and clinical outcomes adjudicated by a clinical events committee. The mean duration of follow-up was 5.3 ± 2.2 years. Results: At 5 years, adjusted safety endpoints were not statistically different between groups; no structural valve deterioration (SVD) event occurred in either group. After adjustment, the Pure AR + MAVD group had a greater change in body surface area–corrected left ventricular (LV) mass reduction (P = .03) compared to the Pure AS patients. Those patients with a baseline LV ejection fraction (LVEF) >55% continued to demonstrate preserved contractility compared to patients with an LVEF ≤55% at baseline (P

Objective: Giant cell arteritis (GCA) may present as proximal aortic pathology requiring surgical intervention. We present our experience with surgical management of GCA in patients presenting with proximal aortic disease. Methods: From January 1993 to May 2020, 184 adult patients were diagnosed with GCA on histopathology after undergoing cardiac surgery. Survival was estimated with Kaplan-Meier method. Reoperation rates were estimated with cumulative incidence accounting for competing risks of death. Results: The most common indication for surgery was ascending aortic aneurysm (n = 179, 97.3%). Stroke occurred in 6 (3.3%), pneumonia in 8 (4.4%), and dialysis in 3 (1.6%) patients. Multivariable analysis found advanced age (hazard ratio [HR], 1.054; 95% confidence interval [CI], 1.026-1.082, P

Background: We have developed a model aimed at identifying preoperative predictors of operative mortality in patients who undergo elective, open thoracoabdominal aortic aneurysm (TAAA) repair. We converted this model into an intuitive nomogram to aid preoperative counseling. Methods: We retrospectively analyzed data from 2884 elective, open TAAA repairs performed between 1986 and 2023 in a single practice. Using clinical and selected operative variables, we built 4 predictive models: multivariable logistic regression (MLR), random forest, support vector machine, and gradient boosting machine. Each model’s predictive effectiveness was evaluated with the C-statistic. Test C-statistics were computed using an 80:20 cross-validation scheme with 1000 iterations. Results: Operative death occurred in 200 patients (6.9%). Test set C-statistics showed that the MLR model (median, 0.68; interquartile range [IQR], 0.65-0.71) outperformed the machine learning models (0.61 [IQR, 0.59-0.64] for random forest; 0.61 [IQR, 0.58-0.64] for support vector machine; 0.65 [IQR, 0.62-0.67] for gradient boosting machine). The final MLR model was based on 7 characteristics: increasing age (odds ratio [OR], 1.04/y; P

Objective: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery that is associated with other adverse outcomes. Recent studies have shown that drainage of pericardial effusion by a posterior pericardial incision reduces the incidence of POAF. An alternative approach is a chest tube placed posteriorly in the pericardium. We evaluated whether the use of a posterior pericardial drain was associated with reduced risk of POAF in patients undergoing coronary artery bypass graft (CABG) and/or aortic valve replacement (AVR). Methods: This observational study included 2535 patients who underwent CABG (n = 1997), AVR (n = 293), or combined CABG and AVR (n = 245) in Iceland from 2002 to 2020. From our study population, 553 (22%) received a 20-Fr posterior pericardial chest tube in addition to standard mediastinal and left pleural drains. The incidence of POAF in patients with and without a posterior pericardial drain was compared before and after 1:1 propensity score matching. Results: Of 2535 patients, 1100 were included in the matched cohort. The incidence of POAF was lower in patients receiving posterior pericardial chest tube drainage compared with the control group, both before (34% vs 43%, P

Background: Whether elderly patients with aortic root or ascending aortic aneurysm (ATAA) would benefit from the new surgical size threshold of 5.0 cm is unknown. This study aimed to evaluate the natural history of ATAA in elderly patients and to compare long-term outcomes of those who underwent initial surveillance versus surgery. Methods: Patients age ≥75 years with an ATAA ≥40 mm were categorized into 2 groups: initial surgery and initial surveillance. The primary outcome was all-cause mortality; Kaplan-Meier curves were plotted for survival. A multivariable Cox proportional hazard regression model was used to identify independent predictors of long-term mortality. Results: The study series comprised 300 patients, including 58 who underwent initial surgery and 242 who received surveillance between July 2010 and September 2022. In the surveillance cohort, the mean aneurysm growth rate was 0.10 cm/year. Comparing surveillance to surgery, at 8 years there was no difference in survival (mean, 77.8 ± 3.4% vs 71.8 ± 9.6%; P = .65). For 116 patients with an initial aneurysm diameter ≥5.0 cm, there was no difference in survival between the 2 groups at 8 years (76.5 ± 7.0% vs 68.4 ± 11.3%; P = .20). Larger body surface area (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.09-1.90; P = .01) and history of smoking (HR, 2.25; 95% CI, 1.27-3.98; P = .01) were identified as predictors of long-term mortality. Conclusions: In our series of elderly patients with ATAA, there was no difference in 8-year survival between initial surveillance and surgical management, with a high competing risk of nonaortic mortality. Surveillance may be a reasonable alternative to surgery for selected older adults with ATAA

Objective: The study objective was to explore medical students' perceptions of mentorship in cardiothoracic surgery in the United States. Methods: A voluntary, anonymous electronic survey was distributed to medical students through the Thoracic Surgery Medical Student Association. The survey included 28 questions across 4 domains: demographic information, current mentorship status, goals and qualities sought in mentorship, and self-reported barriers to mentorship. Results: There were 60 respondents to the survey. A total of 60% identified themselves as male and 35% as White. A total of 75% of students reported having reached out to potential mentors without receiving a response. Lack of access to a cardiothoracic surgery program/mentorship program (37%) or cardiothoracic surgery interest group at one's institution (42%) was the most frequent barrier to mentorship. Overall, 32% reported not having any mentors in cardiothoracic surgery. Students without mentors were more likely to report the lack of cardiothoracic surgery interest groups (53% vs 29%, P = .04). Female students were more likely to prefer a female mentor (48% vs 3%; P

Objective: Machine learning (ML) may allow for improved discernment of hemodynamics and oxygen delivery compared to standard invasive monitoring. We hypothesized that an ML algorithm could predict impaired delivery of oxygen (IDO2) with comparable discrimination to invasive mixed venous oxygen saturation (SvO2) measurement. Methods: A total of 230 patients not on mechanical circulatory support (MCS) managed with a pulmonary artery catheter (PAC) were identified from 1012 patients admitted to a single cardiovascular intensive care unit (CVICU) between April 2021 and January 2022. Physiologic data were collected prospectively by the data analytics engine. Inadequate delivery of oxygen (IDO2) was defined as SvO2 ≤50%. Fifty-four patients were used to train the model, which was then validated in 176 patients. Three simulated monitoring situations were constructed by downsampling the physiologic data set to exclude all SvO2 sources (scenario A); all PAC data but allowing for SvO2 values (scenario B); and all PAC data, including SvO2 and cardiac index (CI) (scenario C). The ML platform then calculated the likelihood of IDO2 for rolling 30-minute intervals and compared these values against the gold standard SvO2 values using receiver operating characteristic (ROC) curve analysis to establish discriminatory power. Results: A total of 1047 laboratory-validated SvO2 values were collected for the validation group. The area under the ROC curve for the IDO2 index was 0.89 (95% confidence interval, 0.87-0.91) with the full data set. When blinded to all PAC and SvO2 sources, the AUC was 0.78 (95% confidence interval, 0.75-0.81). Conclusions: The IDO2 index is capable of detecting SvO2 ≤50% with good discriminatory function in non-MCS CVICU patients in a variety of monitoring situations. Further investigation of IDO2 detection and clinical endpoints is needed.

Objective: The study objective was to assess longitudinal postoperative health-related quality of life among patients with adult congenital heart disease facilitated by a novel electronic medical record–based patient-reported outcomes follow-up platform. Methods: From January 2022 to October 2023, 559 patients with adult congenital heart disease underwent cardiac surgery; 491 (88%) completed a 23-element health-related quality of life questionnaire covering 3 domains (physical, mental, and social) yielding 911 assessments. Automated questionnaires via electronic medical record were sent at 7 days preoperatively and postoperatively at 1, 3, 6, and 12 months. Nonlinear multiphase mixed effects models and boosting approach using multivariate trees were used to assess longitudinal trends and the relationship among patient characteristics, clinical variables, and health-related quality of life outcomes. Results: Mean age of patients was 53 years (range, 19-86), 238 (43%) were female, 109 (20%) were STAT category 3 or 4, postoperative mortality was 0, and stroke was 4 (0.7%). Diagnosis included hypertrophic obstructive cardiomyopathy (276, 50%), anomalous coronary artery (42, 7.5%), congenital aortic valve disease (42, 7.5%), bicuspid aortic valve (64, 12%), and aortic aneurysm (25, 4.5%). Although baseline health-related quality of life scores were below population norms, rapid postoperative increases were seen in physical, mental, and social scores, surpassing population norms between 2 and 6 months. Patients with higher baseline health-related quality of life had higher longitudinal scores. Female patients and those of Black race had higher Area Deprivation Index and lower postoperative physical health-related quality of life scores. Conclusions: Patients with adult congenital heart disease require lifelong medical surveillance and repeated interventions. Our innovative electronic medical record–embedded time-series tool assessing health-related quality of life after cardiac surgery shows improved patient-reported outcomes across mental, physical, and social domains that endure through at least the first postoperative year.

Objective: The study objective was to assess the efficacity of different surgical strategies for atrioesophageal fistula after catheter ablation of atrial fibrillation. Methods: Between January 2010 and April 2023, all patients with a diagnosis of atrioesophageal fistula or pericardo-esophageal fistula after catheter ablation of atrial fibrillation were analyzed retrospectively from the French database EPITHOR. Patients without surgical management were excluded. Results: Eighteen patients were included, 15 with atrioesophageal fistula and 3 with pericardo-esophageal fistula. Median follow-up was 89.5 days with an overall survival of 50%. Five patients underwent esophageal stenting, 2 as a bridge-to-esophagectomy with 50% of survival and 3 in association with esophagus and left atrial direct repair with 66% survival. Primary esophageal repair with flap coverage was performed in 8 patients with 25% survival, most of them with sepsis and neurological failure. Seven patients had an esophagectomy with 71% survival, only 2 of them having a neurological failure. Among them, 5 patients underwent a restorative surgery and are still alive. Four patients had a retrosternal colon interposition, and 1 patient had an esogastric anastomosis. Risk factors for death were neurological failure (hazard ratio [HR], 4.91, 95% CI, 0.95-25.22; P = .0057) in univariate analysis and sepsis (HR, 6.25, 95% CI, 1.17-33.3; P = .032) in multivariate analysis. Esophagectomy tended to offer a survival benefit (HR, 0.163, 95% CI, 0.019-1.340; P = .092). The use of cardiopulmonary bypass did not significantly impact survival (HR, 1.953, 95% CI, 0.392-9.719; P = .413). Conclusions: Aggressive surgical strategies for managing atrioesophageal fistula are mandatory to offer the best chance of survival.

Objective: Well-designed patient education materials (PEMs) increase health literacy, which has been linked to better surgical patient outcomes. The quality of lung cancer surgery PEMs is unknown, however. Here we assessed printed lung cancer surgery PEMs for readability, understandability, actionability, and accessibility. Methods: Various lung cancer programs throughout the United States were contacted for their lung cancer surgery PEMs. The readability of the received materials was calculated using 6 readability tests. Four thoracic surgeon–advanced practice practitioner dyads scored the PEMs for understandability, actionability, and accessibility using the Patient Education Material Assessment Tool and the Accessibility Assessment Tool, with the recommended minimum threshold of 70%. One-sample t tests were performed to compare each parameter against its recommended threshold. Results: Out of 34 institutions contacted, 18 (52.9%) provided PEMs. The average reading level of the PEMs ranged from 7th grade to 11th grade, significantly exceeding the recommended 6th grade health literacy threshold (P

Objective: Iron supplementation may reduce postoperative anemia, blood transfusions, and infections in patients undergoing surgery. We sought to assess efficacy and safety of prophylactic intravenous iron supplementation in patients without anemia undergoing cardiac surgery. Methods: In this investigator-initiated industry-sponsored single-center randomized double-blind parallel group trial, we enrolled patients undergoing coronary bypass, aortic or mitral valve or ascending aortic surgery who fulfilled prespecified iron blood test safety criteria. Patients were randomized to receive either a single intravenous 1000 mg dose of ferric carboxymaltose (FCM) or placebo (saline only). Independent unblinded study nurse administered the infusion with masked lines and cannula 2 to 21 days before surgery. Primary efficacy end point was a composite of in-hospital blood transfusions >2 U and nosocomial infection. The trial was registered in Eudract (2017-004901-41). Results: Altogether 171 patients were screened and 78 randomly assigned to FCM (n = 39) or placebo (n = 39). Trial was prematurely discontinued for futility with regard to reaching the primary end point by the recommendation of the independent data monitoring committee. The primary end point occurred in 3 (7.7%) versus 3 (7.7%) (P = 1.00) of patients assigned to FCM and placebo, respectively, with no difference in blood transfusions >2 U. Fewer hospital readmissions by 3 months follow-up (1 [2.6%] vs 8 [20.5%]; P = .028) were noted in FCM group in a post hoc analysis. Ferritin levels were higher in the FCM group at 3 months indicating more preserved iron stores. Conclusions: Prophylactic treatment with FCM was safe but did not reduce the need for blood transfusions or postoperative infections at index hospitalization in patients without anemia undergoing cardiac surgery.

Objective: The study objective was to investigate the effect of free-edge length on valve performance in bicuspidization repair of congenitally diseased aortic valves. Methods: In addition to a constructed unicuspid aortic valve disease model, 3 representative groups—free-edge length to aortic diameter ratio 1.2, 1.57, and 1.8—were replicated in explanted porcine aortic roots (n = 3) by adjusting native free-edge length with bovine pericardium. Each group was run on a validated ex vivo univentricular system under physiological parameters for 20 cycles. All groups were tested within the same aortic root to minimize inter-root differences. Outcomes included transvalvular gradient, regurgitation fraction, and orifice area. Linear mixed effects model and pairwise comparisons were used to compare outcomes across groups. Results: The diseased control group had a mean transvalvular gradient of 28.3 ± 5.5 mm Hg, regurgitation fraction of 29.6% ± 8.0%, and orifice area of 1.03 ± 0.15 cm2. In ex vivo analysis, all repair groups had improved regurgitation and transvalvular gradient compared with the diseased control group (P

Objective: A novel approach to 3-dimensional morphometry of the thoracic aorta was developed by applying centerline analysis based on least-squares plane fitting, and a preliminary study was conducted using computed tomography imaging data. Methods: We retrospectively compared 3 groups of patients (16 controls without aortic disease, and 16 cases each with acute type B aortic dissection and congenital bicuspid aortic valve). In addition to the standard assessment indices for curvature κ and torsion τ, we conducted coordinate transformation based on the least-squares plane, divided the centerline into 3 representative features (transverse, anterior-posterior, and longitudinal displacements), and analyzed the overall and local displacement in each direction. The transverse displacement, represented by the distance of the centerline from the least-squares plane, was curve-fitted to the damped oscillation waveform. Thereafter, damped oscillation parameters were compared for each group. Results: Curvature κ exhibited a bimodal distribution, with peaks observed in the ascending aorta and aortic arch, and torsion τ exhibited a transition from positive to negative values in the arch. There were significant differences in the mean displacement between the groups for each direction (transverse P = .0083, anteroposterior P = .010, longitudinal P = 1.32 × 10−6). Furthermore, interval integral analysis revealed that several intervals exhibited significant differences between groups in each direction. The amplitude of damped oscillation parameters was significantly larger in the bicuspid aortic valve group than in the control and type B aortic dissection groups. Conclusions: The novel analytical approach permitted a quantitative assessment of the 3-dimensional morphological differences between the control, type B aortic dissection, and bicuspid aortic valve groups.

Objective: Racial disparities in organ allocation may result in differential survival for marginalized groups. This study aims to examine the impact of the November 2017 lung allocation policy change (LAPC) on trends and outcomes of Hispanic lung transplant (LT) recipients. Methods: The United Network for Organ Sharing database was used to identify adult (older than age 18 years) LT recipients between January 2010 and March 2023. Recipients were categorized into 3 self-identified racial groups (Hispanic, non-Hispanic White, and non-Hispanic other). The Mann-Kendall trend test was used to assess the trend in rates of Hispanic LT over 5 years pre- and 5 years post-LAPC. The primary outcome was 1-year mortality. Results: A total of 28,495 recipients from 80 centers were included, with 15,343 (53.8%) prepolicy change and 13,152 (46.2%) postpolicy change. The racial distribution of LT recipients was pre-LAPC: Hispanic: 1013 (6.6%), White: 12,601 (82.1%), Other: 1729 (11.3%) and post-LAPC: Hispanic: 1522 (11.6%), White: 9873 (75.0%), Other: 1757 (13.4%) (P