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Journal and News Scan

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Mateo Marin-Cuartas, Syed Zaid, Jörg Kempfert, Michael A Borger, Serdar Akansel, Thilo Noack, David Holzhey, Tsuyoshi Kaneko, Isaac George, Gorav Ailawadi, Robert L Smith , Arnar Geirrson, Ahmed El-Eshmawi, Dimosthenis Pandis, Suzanne de Waha, Nikolaos Bonaros, Fabien Praz, Maurizio Taramasso, Michele De Bonis, Lenard Conradi, Christian Hagl, Nicolas Doll, Mahmoud Wehbe, Alexey Dashkevich, Manuela de la Cuesta, Jagdip Kang, Zara Dietze, Philipp Kiefer, Gilbert H L Tang

This review article aims to examine the surgical approach to patients with failed mitral transcatheter edge-to-edge repair (M-TEER), focusing on operative challenges, decision-making, and contemporary outcome data. Technical considerations, including device removal and the management of complex mitral valve (MV) anatomy, are discussed. The authors performed a comprehensive literature review and gathered experience from high-volume centers in the surgical management of failed M-TEER. 
 
The key messages from this review are: MV surgery after failed M-TEER is a complex but increasingly necessary procedure as the use of M-TEER grows. It occurs in up to six percent of patients, with a median age of 70–76 years at the time of failure and a median time to failure of less than six months. MV surgery following M-TEER is associated with high mortality and morbidity, with a reported 30-day mortality ranging from 10–40 percent and one-year survival below 60 percent. Functional device failure, structural device failure, MV disease progression, and infective endocarditis are frequent mechanisms of M-TEER failure. Surgical MV repair is the preferred management strategy; however, due to the technical and anatomical complexity, MV replacement is performed much more frequently (with MV repair rates below 10 percent). 
 
The authors concluded that MV surgery after failed M-TEER poses technical challenges due to the presence of altered anatomy, the need for concomitant procedures, and the patient′s comorbidities. While surgical intervention carries increased risks, it remains the definitive treatment for failed M-TEER, offering durable relief from mitral regurgitation (MR). Due to the technical complexities associated with these procedures, strong consideration should be given to transferring patients requiring MV surgery after failed M-TEER to high-volume MV centers. 

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Prabhvir S Marway, Carlos A Campello Jorge, Rana-Armaghan Ahmad, Nicasius Tjahjadi, Himanshu J Patel, Bo Yang, Nicholas S Burris

Aortic arch tears at the time of acute type A dissection are often grouped together and are known to contribute to flow into the residual false lumen, which can increase the risk of delayed complications. This article is the first to investigate the different types of tears, namely residual arch tears (RATs) and distal anastomosis new entry tears (DANEs). It found that DANEs were associated with worse descending aorta modelling and a greater need for reintervention, while RATS were not. An interesting theory suggests that the morphology of tears may contribute to different flow dynamics. For instance, RATs may shunt blood toward the arch vessels and reduce pressure loading of the false lumen, while DANEs may not have an associated pressure relief system. This may have an important effect on technical considerations during the index dissection repair. 

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Lasse Visby, Simone Engdahl, Erik Lilja Secher, Hasse Møller-Sørensen, Henrik Kehlet, René Horsleben Petersen

This prospective observational study examined the association between Pain Catastrophizing Scale (PCS) scores and postoperative pain in 100 patients undergoing multiportal video-assisted thoracic surgery (VATS) lobectomy. The PCS is a 13-item self-report tool measuring catastrophic thinking related to pain, including rumination, magnification, and helplessness, with scores ranging from 0 to 52. Patients completed the PCS preoperatively, and pain was assessed twice daily for two days postoperatively during rest, coughing, use of a positive expiratory pressure (PEP) device, and a five-meter walk test. Those with high PCS scores (greater than or equal to 20) reported significantly greater pain during coughing and walking and were more likely to experience moderate-to-severe pain. Linear regression confirmed PCS as a strong predictor of increased pain. All patients received standardized ERAS protocol pain management. Incorporating PCS may enable more targeted analgesia for breakthrough pain, moving beyond opioid dose titration alone. 

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Hanna Dagnegård, Adriaan W Schneider, Patrick T Timmermans, Natalie Glaser, Solveig M Kolseth, Farkas Vanky, Tomas Gudbjartsson, Rune Haaverstad, Alex Cotovanu, Ulrik Sartipy, Robert J M Klautz, Morten Smerup, Jesper Hjortnaes, North Atlantic Freestyle Collaboration

There is an established difference in presentation, pattern of disease progression, and long-term outcomes in males and females presenting with cardiovascular disease. It is also known that aortic insufficiency (AI) severity and left ventricular dilatation are closely associated in males, but not in females. This article found that females who underwent aortic valve replacement with stentless bioprothesis for aortic insufficiency had worse outcomes compared to males, even after accounting for differences in age. This article raises an important question about whether risk stratification models and current guidelines for intervention in AI need to be revised due to the growing evidence of the contribution of sex to cardiovascular illness. 

Source: Journal of Thoracic and Cardiovascular Surgery Techniques
Author(s): Sameh M. Said, Ali H. Mashadi, Yasin Essa, Henri Justino

This unique case involved a 5-month-old, 6 kg infant who presented with failure to thrive secondary to a large membranous ventricular septal defect (VSD) with a large left-to-right shunt. The patient was born with a near absence of the left lung, and both the mediastinal structures and the heart were shifted to the left hemithorax (a condition known as levoposition). 

During the neonatal period, the infant underwent repair of esophageal atresia via a right thoracotomy. Preoperative imaging, including chest X-rays and cross-sectional imaging, showed significant displacement of the heart and great vessels into the left chest, along with compensatory hyperinflation of the right lung. The authors successfully performed a minimally invasive VSD closure through a left axillary thoracotomy, resulting in an uneventful recovery.  

This is the first case in literature in which left axillary thoracotomy has been utilized for VSD closure in a patient with situs solitus and levoposition of the heart. This challenging anatomy highlighted the potential for a minimally invasive approach, demonstrating the value of preoperative imaging in planning such a complex approach. 

Source: The Journal of Thoracic and Cardiovascular Surgery
Author(s): Jack J. Yi, Tari-Ann Yates, Martha McGilvray, Connor Vinyard, Nicholas Banull, Laurie Sinn, June He, Christian Zemlin, Harold G. Roberts Jr., Matthew R. Schill, Ralph J. Damiano Jr.

This article reports the long-term outcomes of the concomitant Cox-Maze IV procedure in patients with atrial fibrillation who underwent mitral valve surgery. The authors found that the concomitant Maze procedure provided freedom from atrial tachyarrhythmias of 80 percent at five years and 65 percent at 10 years, respectively. In terms of freedom from symptomatic atrial fibrillation recurrence, the rates were 94 percent and 83 percent, respectively. Interestingly, the 10-year survival rate in the propensity-matched group who underwent concomitant Cox Maze group was 54 percent, compared to 43 percent in those without ablation, indicating a significant survival benefit in patients receiving concomitant ablation. 

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Yuan-Liang Zheng, Yu-Ping Yuan, Xiao-Yong Liang, Hong-Li Liao

This single-center prospective trial evaluated same-day discharge (SDD) following subxiphoid thoracoscopic thymectomy in 39 patients with thymic tumors. The SDD completion rate was 92.3percent, with all patients achieving R0 resection. The perioperative complication rate was 5.6 percent, and only one patient required readmission within 30 days due to pneumothorax. The median hospital stay was just 11 hours, with median medical costs amounting to 19,400 renminbi (approximately EU €2,400). These findings suggest that SDD may be safe and feasible for selected patients undergoing this procedure, although larger studies are needed for confirmation. 

Source: European Journal of Cardio-Thoracic Surgery
Author(s): Kira Kuschnerus, Evgenij Potapov, Pia Lanmüller, Christoph Starck, Mi-Young Cho, Joachim Photiadis

The use of mechanical support devices in the pediatric population is an area of active investigation. The authors evaluated all pediatric patients at a single institution who presented in cardiogenic shock and were treated with an Impella device. A total of six patients were observed, who received Impella 2.5, Impella CP, and Impella 5.5, with a median duration of support of seven days (range: 4-45 days). Of these, two patients were bridged to recovery, three to left ventricular assist device (LVAD), and one to heart transplant. Given the absence of mortality or neurological complications, the authors suggest that use the of the Impella device is safe and feasible in this patient population. 

Source: The Annals of Thoracic Surgery
Author(s): Hengrui Liang, Wei Wang, Man Zhang, Runchen Wang, Shunjun Jiang, Fuhao Xu, Chao Yang, Jun Huang, Shuben Li, Zeyong Zhang, Weisen Wu, Diego Gonzalez-Rivas, Jianxing He

This study evaluated the SHURUI single-port (SP) robotic system for uniportal robotic-assisted thoracic surgery (RATS) in lung cancer patients. Unlike conventional multi-incision systems, the SHURUI SP utilizes a single, highly flexible robotic arm, aiming to improve maneuverability and minimize incision size, which is especially beneficial for patients with limited thoracic space. In a phase I/II trial, 35 patients (median age 58) underwent lobectomy or segmentectomy. All surgeries were completed successfully, with no need to switch to other surgical methods or make additional incisions. The median operative time was 155 minutes, with minimal blood loss and no transfusions required. The 30-day complication rate was low at 11.43 percent, with no major issues or readmissions, and patients were typically discharged after four days. Compared to the multiple fully jointed arms required for the da Vinci single-port, the SHURUI SP provides a potential single-port alternative. 

Source: Journal of Thoracic Oncology
Author(s): Niki Gavrielatou, Parmees Fazelib, David L. Rim

This article discusses a promising diagnostic approach aimed at improving patient selection for immune checkpoint inhibitor (ICI) therapies, particularly in non-small cell lung cancer (NSCLC). The current reliance on PD-L1 immunohistochemistry (IHC) as a biomarker has limited sensitivity and specificity. The concept of "touching" refers to the direct molecular interaction between PD-1 and PD-L1 proteins, which can be detected through proximity-based assays such as proximity ligation assay (PLA), Förster resonance energy transfer (FRET), and quantitative immunofluorescence (QIF). The authors highlight new evidence showing that higher PD-1/PD-L1 proximity scores—measured using second-generation PLA—correlate with better treatment responses and survival in ICI-treated patients with NSCLC. 
 
This article is important to the cardiothoracic surgery and thoracic oncology communities, including CTSNet’s global audience, as it signals a potential paradigm shift in how surgical candidates for immunotherapy are selected. As immunotherapy becomes increasingly integrated into multimodal treatment, improved predictive biomarkers such as proximity assays could enhance personalized treatment strategies. 

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