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Journal and News Scan
A recent study by Jad Malas et al. comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in patients less than 60 years of age was presented during the 2024 STS Annual Meeting in San Antonio, Texas. The analysis included data from 2,306 patients less than 60 years old who underwent TAVI or bioprosthetic SAVR between 2013 and 2021 in California, USA. The data originated from the California State Discharge Administrative Database. Almost half of patients less than 60 years old treated for aortic stenosis in California between 2013 and 2021 received TAVI instead of SAVR, with a steady increase in TAVI use for this population over the study period. The annual increase in TAVI use was about five percent. However, the study also showed a 2.5-fold increased risk of death at five years with TAVI compared to SAVR.
This study addressed midterm outcomes with the hemispherical aortic annuloplasty reconstructive technology (HAART) ring used for aortic valve repair (AVr). Seventy-one patients had AVr using the HAART ring—53 had a trileaflet valve and 18 had a bicuspid valve. Their median age was 54 years old and 79 percent were male. Many patients needed concomitant interventions such as arch repair (77 percent) or a root procedure (46 percent). At a mean follow up time of 3.9 ± 1.1 years, freedom from reoperation was 96 percent. Eleven patients had moderate or higher aortic insufficiency (AI) during surveillance, and all of these patients had a trileaflet valve. Three patients suffered ring dehiscence. The authors recommend caution when using the subannular approach for stabilization in patients with trileaflet aortic valves.
New survey data presented at the STS annual meeting showed that female cardiothoracic surgeons have fewer children and are more likely to face infertility than their male colleagues, along with facing more complications when they are pregnant. Leaders in the field suggested systemic changes such as extended parental leave regardless of gender and formal written policies.
This study addressed the long-term results of the réparation à l’étage ventriculaire (REV) procedure for double outlet right ventricle (DORV) and transposition of the great arteries (TGA) with pulmonary stenosis (PS). From 1980 to 2021, 157 patients underwent an REV procedure. Thirteen patients died (8.3 percent), including four in the first postoperative month and two after heart transplants. Survival at 40 years was 89.3 percent. 37 patients required 68 reinterventions on the right ventricular outflow tract (RVOT) including 49 reoperations with a median delay of nine years (8 months to 27 years). The authors concluded that the REV procedure is a good alternative for patients with TGA and double outlet right ventricle with PS, with only a quarter of patients needing redo RVOT surgery.
Conventional cardiac surgery is performed using myocardial protection strategies that were developed decades ago. The context of surgery has changed over this period, with patients now who are older and have more comorbidities. However, the systemic effects of cardioplegia solutions have not been a focus of attention. The authors review the biochemical principles of ischemia, reperfusion and cardioplegic extension of ischemia tolerance. In light of rising patient risk profiles, reduction of surgical trauma and improvement of perioperative morbidity is critical. This means considering the systemic effects of cardioplegia solutions, not just the cardiac effects.
The benefits of early extubation in the operating room (OR) following cardiac surgery remain unproven. In this study, the authors evaluated perioperative outcomes after extubation in the OR versus extubation in the intensive care unit (ICU) in patients who underwent nonemergency isolated coronary artery bypass grafting (CABG). A total of 1,397 patients who underwent nonemergency isolated CABG during a six-year period were analyzed. Among them, 891 (63.8 percent) patients were extubated in the ICU, and 506 (36.2 percent) were extubated in the OR. After propensity score matching, 414 patient pairs were compared. Adjusted comparison did not show differences between the two groups in the incidence of major early postoperative complications such as reintubation, re-exploration for bleeding, stroke, renal failure, or thirty-day mortality. Furthermore, patients extubated in the OR had shorter ICU (P < 0.0001) and hospital stays (P < 0.0001), were more frequently discharged directly home (P < 0.0001), and presented with a lower thirty-day readmission rate (P = 0.04). Based on these results, the authors suggest a wider adoption of routine OR extubation for nonemergency CABG.
Infants awaiting pediatric heart transplantation (PHT) have long waitlist duration and high mortality due to donor shortage. This study examined whether increased donor-recipient weight ratio (DRWR) higher than 2.0, the recommended cutoff, resulted in adverse outcomes. 1,392 infants undergoing PHT between 2007 and 2020 were included. They were divided into three groups: A (DRWR ≤ 1.0, n = 239); B (DRWR 1.0–2.0, n = 947; C (DRWR > 2, n = 206). DRWR ranged from 0.5 to 4.1 and other variables were comparable between groups. Patients in group C were more likely to be ventilated, receive an ABO blood group-incompatible heart, and have longer donor ischemia times. The DRWR group was not associated with operative death in either congenital or cardiomyopathy patients. Infants in group C had shorter waitlist durations and no demonstrable increase in adverse outcomes.
A recently published article showed the benefit of TEER compared to mitral valve surgery in older, sicker patients with a high risk in surgery. Based on the French administrative hospital discharge database, the study collected information from all consecutive patients treated for primary or secondary mitral regurgitation with isolated TEER or isolated mitral valve surgery (repair or replacement) between 2012 and 2022. A total of 57,030 patients were found in the database, and after propensity score matching, a total of 2,160 patients were included for analysis in each arm. This study has led to controversy and a heated discussion within the cardiovascular community. In his article, Michael O'Riordan from TCTMD interviews the study's primary author and other experts in the field, providing insights into this issue and a comprehensive overview of the topic.
In this joint statement, ERAS and STS present a list of potential program elements, literature review, and a consensus on ERAS clinical practice. The statement is an update to the 2019 guidance and includes new clinical data.
In findings presented at the STS annual meeting, the ten-year data showed the survival benefit of multi- over single-arterial grafting in all but patients who are severely obese. The study used data from the STS Adult Cardiac Surgery Database to look at patients who underwent isolated CABG over a ten-year period. The long-term survival rate was significantly better for patients who received multiple arterial grafting. The authors of the study acknowledged the reasons surgeons have not taken this data into account as lack of education and suspicion around the evidence.